An Evidence-Based Initiative to Reduce Alarm Fatigue in a Burn Intensive Care Unit.

BACKGROUND: Alarm fatigue occurs when nurses are exposed to multiple alarms of mixed significance and become desensitized to alarms to the point that a critical alarm may receive no response or a delayed response. In burn intensive care units, reducing the risk of alarm fatigue is uniquely challenging because of the critically ill patient population and the nature of burn skin injuries. Nurses and the interdisciplinary team can become fatigued and desensitized to alarms, decreasing response rates for necessary interventions. OBJECTIVE: To decrease the risk of alarm fatigue by using an initiative designed to reduce nonactionable and false alarms in a burn intensive care unit. METHODS: Baseline data (alarm count per patient-day by alarm type) were collected for 1 month before education and implementation of evidence-based interventions. Data were collected every 6 months for 2 years. INTERVENTIONS: A series of interventions included raising awareness of the risks associated with alarm fatigue, customizing alarm parameters and default settings, providing education on electrode placement and daily electrode changes, using physical reminders, and consistently sharing alarm data. The education, delivered in modules, aligned with the evidence-based interventions. RESULTS: Preintervention baseline data were compared to postintervention data at 6, 12, 18, and 24 months. The results showed a significantly sustained reduction (P < .001) in total alarm rate over time. CONCLUSION: A quality improvement initiative based on evidence-based practice can contribute to a sustainable reduction in nonactionable and false alarms, ultimately improving patient safety.

Relationships between nurses' experiences of workplace violence, emotional exhaustion and patient safety.

BACKGROUND: The rising rate of workplace violence in hospitals is a serious concern. While leading organisations recommend implementing interventions to address workplace violence, little is known about the workplace violence relationship between patients and visitors, and how it affects nurses' emotional exhaustion and their perceptions of patient safety. AIMS: The study's purpose was to understand the status of workplace violence in hospitals and the relationships between nurses' experiences of workplace violence, emotional exhaustion, and perceptions of patient safety. METHODS: This cross-sectional analysis used data from a survey conducted at a large academic medical centre using the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture plus additional measures of workplace violence and emotional exhaustion. RESULTS: Nurses reported more occurrences of verbal violence than physical violence. Nurses' experiences of workplace violence negatively affect nurses' emotional exhaustion and patient-safety perceptions. Moreover, nurses' emotional exhaustion mediated the relationship between verbal abuse and patient-safety perceptions. CONCLUSIONS: Interventions to reduce nurses' emotional exhaustion and strengthen resilience can mitigate the negative effects of verbal abuse and to some extent the effects of physical violence.

A Patient Reported Approach to Identify Medical Errors and Improve Patient Safety in the Emergency Department.

OBJECTIVE: Medical errors in the emergency department (ED) occur frequently. Yet, common adverse event detection methods, such as voluntary reporting, miss 90% of adverse events. Our objective was to demonstrate the use of patient-reported data in the ED to assess patient safety, including medical errors. METHODS: Analysis of patient-reported survey data collected over a 1-year period in a large, academic emergency department. All patients who provided a valid e-mail or cell phone number received a brief electronic survey within 24 hours of their ED encounter by e-mail or text message with Web link. Patients were asked about ED safety-related processes. RESULTS: From Aug 2012 to July 2013, we sent 52,693 surveys and received 7103 responses (e-mail response rate 25.8%), including 2836 free-text comments (44% of respondents). Approximately 242 (8.5%) of 2836 comments were classified as potential safety issues, including 12 adverse events, 40 near-misses, 23 errors with minimal risk of harm, and 167 general safety issues (eg, gaps in care transitions). Of the 40 near misses, 35 (75.0%) of 40 were preventable. Of the 52 adverse events or near misses, 5 (9.6%) were also identified via an existing patient occurrence reporting system. CONCLUSIONS: A patient-reported approach to assess ED-patient safety yields important, complementary, and potentially actionable safety information.

Utilization of rapid response resources and outcomes in a comprehensive cancer center*.

OBJECTIVE: To compare the differences in characteristics and outcomes of cancer center patients with other subspecialty medical patients reviewed by rapid response teams. DESIGN: A retrospective cohort study of hospitalized general medicine patients, subspecialty medicine patients, and oncology patients requiring rapid response team activation over a 2-year period from September 2009 to August 2011. PATIENTS: Five hundred fifty-seven subspecialty medical patients required rapid response team intervention. SETTING: A single academic medical center in the southeastern United States (800+ bed) with a dedicated 50-bed inpatient comprehensive cancer care center. INTERVENTIONS: Data abstraction from computerized medical records and a hospital quality improvement rapid response database. MEASUREMENTS AND MAIN RESULTS: Of the 557 patients, 135 were cancer center patients. Cancer center patients had a significantly higher Charlson Comorbidity Score (4.4 vs 2.9, < 0.001). Cancer center patients had a significantly longer hospitalization period prior to rapid response team activation (11.4 vs 6.1 d, p < 0.001). There was no significant difference between proportions of patients requiring ICU transfer between the two groups (odds ratio, 1.2; 95% CI, 0.8-1.8). Cancer center patients had a significantly higher in-hospital mortality compared with the other subspecialty medical patients (33% vs 18%; odds ratio, 2.2; 95% CI, 1.50-3.5). If the rapid response team event required an ICU transfer, this finding was more pronounced (56% vs 23%; odds ratio, 4.0; 95% CI, 2.0-7.8). The utilization of rapid response team resources during the 2-year period studied was also much higher for the oncology patients with 37.34 activations per 1,000 patient discharges compared with 20.86 per 1,000 patient discharges for the general medical patients. CONCLUSIONS: Oncology patients requiring rapid response team activation have a significantly higher in-hospital mortality rate, particularly if the rapid response team requires ICU transfer. Oncology patients also utilize rapid response team resources at a much higher rate.

Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units.

BACKGROUND: An evidence-based teamwork system, Team-STEPPS, was implemented in an academic medical center's pediatric and surgical ICUs. METHODS: A multidisciplinary change team of unit- and department-based leaders was formed to champion the initiative; develop a customized action plan for implementation; train frontline staff; and identify process, team outcome, and clinical outcome objectives for the intervention. The evaluation consisted of interviews with key staff, teamwork observations, staff surveys, and clinical outcome data. RESULTS: All PICU, SICU, and respiratory therapy staff received TeamSTEPPS training. Staff reported improved experience of teamwork posttraining and evaluated the implementation as effective. Observed team performance significantly improved for all core areas of competency at 1 month postimplementation and remained significantly improved for most of the core areas of competency at 6 and 12 months postimplementation. Survey data indicated improvements in staff perceptions of teamwork and communication openness in both units. From pre- to posttraining, the average time for placing patients on extracorporeal membrane oxygenation (ECMO) decreased significantly. The average duration of adult surgery rapid response team events was 33% longer at postimplementation versus pre-implementation. The rate of nosocomial infections at postimplementation was below the upper control limit for seven out of eight months in both the PICU and the SICU. CONCLUSIONS: The implementation of a customized 2.5-hour version of the TeamSTEPPS training program in two areas--the PICU and SICU--that had demonstrated successful ability to innovate suggests that the training was successful.

Innovations at the intersection of academia and practice: facilitating graduate nursing students' learning about quality improvement and patient safety.

OBJECTIVE: Quality and safety are high priorities for US hospitals today. This focus is likely to intensify, given the rapidly changing and complex health care environment. While health care organizations are initiating a number of strategies to improve care and respond to changing regulatory and policy requirements, many clinicians practicing in them have not received training on quality and safety as a part of their formal education. We describe an academic-practice partnership formed to educate graduate-level nursing students about health care quality and safety. METHODS: Our approach combines theories, methods, and tools of improvement with practice-based learning, thus providing students with an opportunity to apply improvement theories and methods in a health care setting. Student teams are paired with organizational preceptors to conduct projects that address improvement opportunities in health care organizations. RESULTS: We share the structures-processes-outcomes of our partnership, including the content of our course, development of projects, and how projects are used to facilitate shared student-faculty-organizational learning. CONCLUSIONS: Suggestions are offered that address continued course improvement as well as broader improvements in the education of health professionals about quality and patient safety.

Organizational accountability in a just culture.

Policies and procedures exist to safeguard patients and protect them from harm; however, a deeper understanding as to why a particular sentinel event occurred and less focus on the individual who made the error can have positive outcomes. Nursing leaders should strive to maintain a just culture to promote reporting and learning in their facility, thereby creating a culture of safety for patients.