RESUMEN
BACKGROUND: The VA Community Living Center (CLC) Unannounced Survey Program aims to assess standards of care set by the government to protect residents. PURPOSE: To describe patterns of practice failures in nursing surveillance causing or having potential to cause immediate jeopardy, as defined by the Centers for Medicare and Medicaid Services. METHODS: Using CLC survey data consisting of 200 statements of deficiency (SODs) for 2018 to 2019, we collected a SOD sample (n = 20) of immediate jeopardy events. They were described using descriptive statistics and discourse content analysis. FINDINGS: We identified clinical events, their duration, work shift, and nursing skill mix for each SOD. Most to least common themes about failures in nursing surveillance were acquisition/transfer of information; decision-making; and early recognition of problems. DISCUSSION: Our analysis of nursing surveillance failures in CLC immediate jeopardy SODs provides insight into opportunities for registered nurses and the nursing skill mix to reduce avoidable harms.
Asunto(s)
Casas de Salud/normas , Proceso de Enfermería/normas , United States Department of Veterans Affairs/estadística & datos numéricos , Administración Hospitalaria/métodos , Humanos , Casas de Salud/organización & administración , Casas de Salud/estadística & datos numéricos , Proceso de Enfermería/tendencias , Encuestas y Cuestionarios , Estados Unidos , United States Department of Veterans Affairs/organización & administración , Veteranos/estadística & datos numéricosRESUMEN
BACKGROUND: Surgical teams aspire to be safe and avoid preventable deaths. A lack of teamwork has been associated with safety failures, including adverse events and errors. PURPOSE: The purpose of the pilot study was to: (1) modify the Observational Teamwork Assessment in Surgery (OTAS) and the original data collection method to measure registered nurse (RN) teamwork during the intraoperative phase of 5 open heart surgical procedures and (2) recommend strategies to further test the reliability and validity of the modified OTAS. METHODS: This was a pilot study of the OTAS using direct observation. RESULTS: Although characterized as psychometrically rigorous in prior systematic reviews, using the OTAS to measure RN teamwork in the intraoperative phase of cardiac surgery revealed deficits in its content validity and reliability. The OTAS and its original data collection method were modified. CONCLUSION: Recommendations for further use of the modified OTAS to increase its reliability and validity are given.
