The Stay S.A.F.E. Strategy for Managing Interruptions Reduces Distraction Time in the Simulated Clinical Setting.

Interruptions occurring during the delivery of health care are frequent and create a serious threat to patient safety. It is important to test strategies directed at decreasing the negative effects of interruptions. The purpose of this pilot study was to test the Stay S.A.F.E. strategy for managing interruptions. A pretest, posttest quasi-experimental design was used to test the primary hypothesis that the Stay S.A.F.E. interruption management strategy would significantly (P < .05) reduce distraction time away from a primary task following an interruption. Twenty nurses with a median of 12 years of experience (range: 1-45 years) participated in the study. There was a significant decrease in the amount of time that participants were distracted away from the primary task between the pretest (134.47 seconds, SD = 6.87) and posttest (6.08 seconds, SD = 1.27) periods; P = .0004. The results of this study suggest that the Stay S.A.F.E. interruption management strategy was effective in reducing the length of time participants were distracted from the primary task in a simulated clinical setting. In addition, nurses confirmed the reports of others that interruptions are frequent, dangerous, and result in errors.

An Analysis of US Emergency Department Visits From Falls From Skiing, Snowboarding, Skateboarding, Roller-Skating, and Using Nonmotorized Scooters.

We analyzed the US incidence of emergency department (ED) visits and hospitalizations for falls from skiing, snowboarding, skateboarding, roller-skating, and nonmotorized scooters in 2011. The outcome was hospital admission from the ED. The primary analysis compared pediatric patients aged 1 to 17 years to adults aged 18 to 44 years. The analysis used ICD-9 E-codes E885.0 to E885.4 using discharge data from the Nationwide Emergency Department Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. Approximately 214 000 ED visits met study criteria. Skiing injuries had the highest percentage of hospitalizations (3.30% in pediatric patients and 6.65% in adults 18-44 years old). Skateboard and snowboard injuries were more likely to require hospitalization than roller skating injuries in pediatric patients (odds ratio = 2.42; 95% CI = 2.14-2.75 and odds ratio = 1.83; 95% CI =1.55-2.15, respectively). In contrast, skateboard and snowboard injuries were less severe than roller-skating injuries in adults.

Using Computer Simulation to Study Nurse-to-Patient Ratios in an Emergency Department.

OBJECTIVE: To study the impact of nurse-to-patient ratios on patient length of stay (LOS) in computer simulations of emergency department (ED) care. METHODS: Multiple 24-hour computer simulations of emergency care were used to evaluate the impact of different minimum nurse-to-patient ratios related to ED LOS, which is composed of wait (arrival to bed placement) and bedtime (bed placement to leave bed). RESULTS: Increasing the number of patients per nurse resulted in increased ED LOS. Mean bedtimes in minutes were impacted by nurse-to-patient ratios. CONCLUSIONS: In computer simulation of ED care, increasing the number of patients per nurse resulted in increasing delays in care (ie, increasing bedtime).

The impact of age and gender on resource utilization and profitability in ED patients seen and released.

OBJECTIVE: To determine how age and gender impact resource utilization and profitability in patients seen and released from an Emergency Department (ED). METHODS: Billing data for patients seen and released from an Emergency Department (ED) with >100,000 annual visits between 2003 and 2009 were collected. Resource utilization was measured by length of stay (placement in ED bed to leaving the bed) and direct clinical costs (e.g., ED nursing salary and benefits, pharmacy and supply costs, etc.) estimated using relative value unit cost accounting. The primary outcome of profitability was defined as contribution margin per hour. A patient's contribution margin by insurance type (excluding self-pay) was determined by subtracting direct clinical costs from facility contractual revenue. Results are expressed as medians and US dollars. RESULTS: In 523 882 outpatient ED encounters, as patients' aged, length of stay and direct clinical cost increased while the contribution margin and contribution margin by hour decreased. Women of childbearing age (15-44) had higher median length of stay (2.1 hours), direct clinical cost ($149), and contribution margin per hour ($103/hour) than men of same age (1.7, $131, $85/hour, respectively). Resource utilization and profitability by gender were similar in children and adults over 45. CONCLUSION: Resource utilization increased and profitability decreased with increasing age in patients seen and released from an ED. The care of women of childbearing age resulted in higher resource utilization and higher profitability than men of the same age. No differences in resource utilization or profitability by gender were observed in children and adults over 45.

Eye tracking as a debriefing mechanism in the simulated setting improves patient safety practices.

INTRODUCTION: Human patient simulation has been widely adopted in healthcare education despite little research supporting its efficacy. The debriefing process is central to simulation education, yet alternative evaluation methods to support providing optimal feedback to students have not been well explored. Eye tracking technology is an innovative method for providing objective evaluative feedback to students after a simulation experience. The purpose of this study was to compare 3 forms of simulation-based student feedback (verbal debrief only, eye tracking only, and combined verbal debrief and eye tracking) to determine the most effective method for improving student knowledge and performance. METHODS: An experimental study using a pretest-posttest design was used to compare the effectiveness of 3 types of feedback. The subjects were senior baccalaureate nursing students in their final semester enrolled at a large university in the northeast United States. Students were randomly assigned to 1 of the 3 intervention groups. RESULTS: All groups performed better in the posttest evaluation than in the pretest. Certain safety practices improved significantly in the eye tracking-only group. These criteria were those that required an auditory and visual comparison of 2 artifacts such as "Compares patient stated name with name on ID band." CONCLUSIONS: Eye tracking offers a unique opportunity to provide students with objective data about their behaviors during simulation experiences, particularly related to safety practices that involve the comparison of patient stated data to an artifact such as an ID band. Despite the limitations of current eye tracking technology, there is significant potential for the use of this technology as a method for the study and evaluation of patient safety practices.

How do interruptions impact nurses' visual scanning patterns when using barcode medication administration systems?

While barcode medication administration (BCMA) systems have the potential to reduce medication errors, they may introduce errors, side effects, and hazards into the medication administration process. Studies of BCMA systems should therefore consider the interrelated nature of health information technology (IT) use and sociotechnical systems. We aimed to understand how the introduction of interruptions into the BCMA process impacts nurses' visual scanning patterns, a proxy for one component of cognitive processing. We used an eye tracker to record nurses' visual scanning patterns while administering a medication using BCMA. Nurses either performed the BCMA process in a controlled setting with no interruptions (n=25) or in a real clinical setting with interruptions (n=21). By comparing the visual scanning patterns between the two groups, we found that nurses in the interruptive environment identified less task-related information in a given period of time, and engaged in more information searching than information processing.

Is outpatient emergency department care profitable? Hourly contribution margins by insurance for patients discharged from an emergency department.

STUDY OBJECTIVE: We determine the contribution margin per hour (ie, profit) by facility evaluation and management (E&M) billing level and insurance type for patients treated and discharged from an urban, academic emergency department (ED). METHODS: Billing and demographic data for patients treated and discharged from an ED with greater than 100,000 annual visits between 2003 and 2009 were collected from hospital databases. The primary outcome was contribution margin per patient per hour. Contribution margin by insurance type (excluding self-pay) was determined at the patient level by subtracting direct clinical costs from contractual revenue. Hospital overhead and physician expenses and revenue were not included. RESULTS: In 523,882 outpatient ED encounters, contribution margin per hour increased with increasingly higher facility billing level for patients with commercial insurance ($70 for E&M level 1 to $177 at E&M level 5) but decreased for patients with Medicare ($44 for E&M level 1 to $29 at E&M level 5) and Medicaid ($73 for E&M level 1 to -$16 at E&M level 5). During the study years, cost, charge, revenue, and length of stay increased for each billing level. CONCLUSION: In our hospital, contribution margin per hour in ED outpatient encounters varied significantly by insurance type and billing level; commercially insured patients were most profitable and Medicaid patients were least profitable. Contribution margin per hour for patients commercially insured increased with higher billing levels. In contrast, for Medicare and Medicaid patients, contribution margin per hour decreased with higher billing levels, indicating that publicly insured ED outpatients with higher acuity (billing level) are less profitable than similar, commercially insured patients.

Bar-code verification: reducing but not eliminating medication errors.

Using observation, eye tracking, and clinical simulation with embedded errors, we studied the impact of bar-code verification on error identification and recovery during medication administration. Data supported that bar-code verification may reduce but does not eliminate patient identification (ID) and medication errors during clinical simulation of medication administration.

Nurses' behaviors and visual scanning patterns may reduce patient identification errors.

Patient identification (ID) errors occurring during the medication administration process can be fatal. The aim of this study is to determine whether differences in nurses' behaviors and visual scanning patterns during the medication administration process influence their capacities to identify patient ID errors. Nurse participants (n = 20) administered medications to 3 patients in a simulated clinical setting, with 1 patient having an embedded ID error. Error-identifying nurses tended to complete more process steps in a similar amount of time than non-error-identifying nurses and tended to scan information across artifacts (e.g., ID band, patient chart, medication label) rather than fixating on several pieces of information on a single artifact before fixating on another artifact. Non-error-indentifying nurses tended to increase their durations of off-topic conversations-a type of process interruption-over the course of the trials; the difference between groups was significant in the trial with the embedded ID error. Error-identifying nurses tended to have their most fixations in a row on the patient's chart, whereas non-error-identifying nurses did not tend to have a single artifact on which they consistently fixated. Finally, error-identifying nurses tended to have predictable eye fixation sequences across artifacts, whereas non-error-identifying nurses tended to have seemingly random eye fixation sequences. This finding has implications for nurse training and the design of tools and technologies that support nurses as they complete the medication administration process.

Geography and travel distance impact emergency department visits.

BACKGROUND: Little has been written about the geographic basis of emergency department (ED) visits. OBJECTIVE: The objective of this study is to describe the impact of geography on ED visits. METHODS: A retrospective analysis was conducted of ED visits during a 1-year period at a single institution using spatial interaction analysis that models the pattern of flow between a series of origins (census block groups) and a destination (ED). Patients were assigned to census block groups based upon their verified home address. The study hospital is the only Level I trauma, pediatric, and tertiary referral center in the area. There are 11 other hospitals with EDs within a 40-mile radius. Each patient visit within this radius, including repeat visits, was included. Patients with an invalid home address, a post office box address, or those who lived outside a 40-mile radius were excluded. ED visits per 100 population were calculated for each census block group. RESULTS: There were 98,584 (95%) visits by 63,524 patients that met study inclusion criteria. Visit rates decreased with increasing distance from the ED (p < 0.0001). Nineteen percent of patients lived within 2 miles, 48% within 4 miles, and 92% within 12 miles of the ED. The Connecticut border, 7 miles south of the ED (p < 0.0001), the Connecticut River, 1 mile west of the ED (p < 0.0001), and the presence of a competing ED within 1 mile (p < 0.0001) negatively impacted block group ED visit rates. Travel distance was related to the percentage of visits that were high acuity (p < 0.0001), daytime (p < 0.01), or resulted in admission (p < 0.0001). CONCLUSIONS: Geography and travel distance significantly impact ED visits.

Emergency department medication lists are not accurate.

BACKGROUND: Medication errors are a common source of adverse events. Errors in the home medication list may impact care in the Emergency Department (ED), the hospital, and the home. Medication reconciliation, a Joint Commission requirement, begins with an accurate home medication list. OBJECTIVE: To evaluate the accuracy of the ED home medication list. METHODS: Prospective, observational study of patients aged > 64 years admitted to the hospital. After obtaining informed consent, a home medication list was compiled by research staff after consultation with the patient, their family and, when appropriate, their pharmacy and primary care doctor. This home medication list was not available to ED staff and was not placed in the ED chart. ED records were then reviewed by a physician, blinded to the research-generated home medication list, using a standardized data sheet to record the ED list of medications. The research-generated home medication list was compared to the standard medication list and the number of omissions, duplications, and dosing errors was determined. RESULTS: There were 98 patients enrolled in the study; 56% (55/98, 95% confidence interval [CI] 46-66%) of the medication lists for these patients had an omission and 80% (78/98, 95% CI 70-87%) had a dosing or frequency error; 87% of ED medication lists had at least one error (85/98, 95% CI 78-93%). CONCLUSION: Our findings now add the ED to the list of other areas within health care with inaccurate medication lists. Strategies are needed that support ED providers in obtaining and communicating accurate and complete medication histories.

Strategies used by critical care nurses to identify, interrupt, and correct medical errors.

BACKGROUND: Medical errors are common in intensive care units. Nurses are uniquely positioned to identify, interrupt, and correct medical errors and to minimize preventable adverse outcomes. Nurses are increasingly recognized as playing a role in reducing medical errors, but only recently have their error-recovery strategies been described. OBJECTIVES: To describe error-recovery strategies used by critical care nurses. METHODS: Data were collected by audio taping focus groups with 20 nurses from 5 critical care units at 2 urban university medical centers and 2 community hospitals on the East and West coasts of the United States. Transcript content was analyzed as recommended by Krueger and Casey. RESULTS: Analysis of focus group data revealed that nurses in critical care settings use 17 strategies to identify, interrupt, and correct errors. Nurses used 8 strategies to identify errors: knowing the patient, knowing the "players," knowing the plan of care, surveillance, knowing policy/procedure, double-checking, using systematic processes, and questioning. Nurses used 3 strategies to interrupt errors: offering assistance, clarifying, and verbally interrupting. Nurses used 6 strategies to correct errors: persevering, being physically present, reviewing or confirming the plan of care, offering options, referencing standards or experts, and involving another nurse or physician. CONCLUSIONS: These results reflect the pivotal role that critical care nurses play in the recovery of medical errors and ensuring patient safety. Several error-recovery strategies identified in this study were also reported by emergency nurses, providing further empirical support for nurses' role in the recovery of medical errors as proposed in the Eindhoven model.

Error identification and recovery by student nurses using human patient simulation: opportunity to improve patient safety.

This study examined types of errors that occurred or were recovered in a simulated environment by student nurses. Errors occurred in all four rule-based error categories, and all students committed at least one error. The most frequent errors occurred in the verification category. Another common error was related to physician interactions. The least common errors were related to coordinating information with the patient and family. Our finding that 100% of student subjects committed rule-based errors is cause for concern. To decrease errors and improve safe clinical practice, nurse educators must identify effective strategies that students can use to improve patient surveillance.

Emergency department patients who stay more than 6 hours contribute to crowding.

BACKGROUND: Admitted and discharged patients with prolonged emergency department (ED) stays may contribute to crowding by utilizing beds and staff time that would otherwise be used for new patients. OBJECTIVES: To describe patients who stay > 6 h in the ED and determine their association with measures of crowding. METHODS: This was a retrospective, observational study carried out over 1 year at a single, urban, academic ED. RESULTS: Of the 96,562 patients seen, 16,017 (17%) stayed > 6 h (51% admitted). When there was at least one patient staying > 6 h, 60% of the time there was at least one additional patient in the waiting room who could not be placed in an ED bed because none was open. The walk-out rate was 0.34 patients/hour when there were no patients staying in the ED > 6 h, vs. 0.77 patients/hour walking out when there were patients staying > 6 h in the ED (p < 0.001). When the ED contained more than 3 patients staying > 6 h, a trend was noted between increasing numbers of patients staying in the ED > 6 h and the percentage of time the ED was on ambulance diversion (p = 0.011). CONCLUSION: In our ED, having both admitted and discharged patients staying > 6 h is associated with crowding.

Patient identification errors are common in a simulated setting.

STUDY OBJECTIVE: We evaluate the frequency and accuracy of health care workers verifying patient identity before performing common tasks. METHODS: The study included prospective, simulated patient scenarios with an eye-tracking device that showed where the health care workers looked. Simulations involved nurses administering an intravenous medication, technicians labeling a blood specimen, and clerks applying an identity band. Participants were asked to perform their assigned task on 3 simulated patients, and the third patient had a different date of birth and medical record number than the identity information on the artifact label specific to the health care workers' task. Health care workers were unaware that the focus of the study was patient identity. RESULTS: Sixty-one emergency health care workers participated--28 nurses, 16 technicians, and 17 emergency service associates--in 183 patient scenarios. Sixty-one percent of health care workers (37/61) caught the identity error (61% nurses, 94% technicians, 29% emergency service associates). Thirty-nine percent of health care workers (24/61) performed their assigned task on the wrong patient (39% nurses, 6% technicians, 71% emergency service associates). Eye-tracking data were available for 73% of the patient scenarios (133/183). Seventy-four percent of health care workers (74/100) failed to match the patient to the identity band (87% nurses, 49% technicians). Twenty-seven percent of health care workers (36/133) failed to match the artifact to the patient or the identity band before performing their task (33% nurses, 9% technicians, 33% emergency service associates). Fifteen percent (5/33) of health care workers who completed the steps to verify patient identity on the patient with the identification error still failed to recognize the error. CONCLUSION: Wide variation exists among health care workers verifying patient identity before performing everyday tasks. Education, process changes, and technology are needed to improve the frequency and accuracy of patient identification.

Emergency department admissions are more profitable than non-emergency department admissions.

STUDY OBJECTIVE: We compare the contribution margin per case per hospital day of emergency department (ED) admissions with non-ED admissions in a single hospital, a 600-bed, academic, tertiary referral, Level I trauma center with an annual ED census of 100,000. METHODS: This was a retrospective comparison of the contribution margin per case per day for ED and non-ED inpatient admissions for fiscal years 2003, 2004, and 2005 (October 1 through September 30). Contribution margin is defined as net revenue minus total direct costs; it is then expressed per case per hospital day. Service lines are a set of linked patient care services. Observation admissions and outpatient services are not included. Resident expenses (eg, salary and benefits) and revenue (ie, Medicare payment of indirect medical expenses and direct medical expenses) are not included. Overhead expenses are not included (eg, building maintenance, utilities, information services support, administrative services). RESULTS: For fiscal year 2003 through fiscal year 2005, there were 51,213 ED and 57,004 non-ED inpatient admissions. Median contribution margin per day for ED admissions was higher than for non-ED admissions: ED admissions $769 (interquartile range $265 to $1,493) and non-ED admissions $595 (interquartile range $178 to $1,274). Median contribution margin per day varied by site of admissions, by diagnosis-related group, by service line, and by insurance type. CONCLUSION: In summary, ED admissions in our institution generate a higher contribution margin per day than non-ED admissions.

Providers do not verify patient identity during computer order entry.

INTRODUCTION: Improving patient identification (ID), by using two identifiers, is a Joint Commission safety goal. Appropriate identifiers include name, date of birth (DOB), or medical record number (MRN). OBJECTIVES: The objectives were to determine the frequency of verifying patient ID during computerized provider order entry (CPOE). METHODS: This was a prospective study using simulated scenarios with an eye-tracking device. Medical providers were asked to review 10 charts (scenarios), select the patient from a computer alphabetical list, and order tests. Two scenarios had embedded ID errors compared to the computer (incorrect DOB or misspelled last name), and a third had a potential error (second patient on alphabetical list with same last name). Providers were not aware the focus was patient ID. Verifying patient ID was defined as looking at name and either DOB or MRN on the computer. RESULTS: Twenty-five of 25 providers (100%; 95% confidence interval [CI] = 86% to 100%) selected the correct patient when there was a second patient with the same last name. Two of 25 (8%; 95% CI = 1% to 26%) noted the DOB error; the remaining 23 ordered tests on an incorrect patient. One of 25 (4%, 95% CI = 0% to 20%) noted the last name error; 12 ordered tests on an incorrect patient. No participant (0%, 0/107; 95% CI = 0% to 3%) verified patient ID by looking at MRN prior to selecting a patient from the alphabetical list. Twenty-three percent (45/200; 95% CI = 17% to 29%) verified patient ID prior to ordering tests. CONCLUSIONS: Medical providers often miss ID errors and infrequently verify patient ID with two identifiers during CPOE.

Designing property specifications to improve the safety of the blood transfusion process.

Computer scientists use a number of well-established techniques that have the potential to improve the safety of patient care processes. One is the formal definition of a process; the other is the formal definition of the properties of a process. Even highly regulated processes, such as laboratory specimen acquisition and transfusion therapy, use guidelines that may be vague, misunderstood, and hence erratically implemented. Examining processes in a systematic way has led us to appreciate the potential variability in routine health care practice and the impact of this variability on patient safety in the clinical setting. The purpose of this article is to discuss the use of innovative computer science techniques as a means of formally defining and specifying certain desirable goals of common, high-risk, patient care processes. Our focus is on describing the specification of process properties, that is, the high-level goals of a process that ultimately dictate why a process should be performed in a given manner.

Increasing patient safety and efficiency in transfusion therapy using formal process definitions.

The administration of blood products is a common, resource-intensive, and potentially problem-prone area that may place patients at elevated risk in the clinical setting. Much of the emphasis in transfusion safety has been targeted toward quality control measures in laboratory settings where blood products are prepared for administration as well as in automation of certain laboratory processes. In contrast, the process of transfusing blood in the clinical setting (ie, at the point of care) has essentially remained unchanged over the past several decades. Many of the currently available methods for improving the quality and safety of blood transfusions in the clinical setting rely on informal process descriptions, such as flow charts and medical algorithms, to describe medical processes. These informal descriptions, although useful in presenting an overview of standard processes, can be ambiguous or incomplete. For example, they often describe only the standard process and leave out how to handle possible failures or exceptions. One alternative to these informal descriptions is to use formal process definitions, which can serve as the basis for a variety of analyses because these formal definitions offer precision in the representation of all possible ways that a process can be carried out in both standard and exceptional situations. Formal process definitions have not previously been used to describe and improve medical processes. The use of such formal definitions to prospectively identify potential error and improve the transfusion process has not previously been reported. The purpose of this article is to introduce the concept of formally defining processes and to describe how formal definitions of blood transfusion processes can be used to detect and correct transfusion process errors in ways not currently possible using existing quality improvement methods.

Prehospital hypotension is a predictor of the need for an emergent, therapeutic operation in trauma patients with normal systolic blood pressure in the emergency department.

BACKGROUND: To determine whether prehospital hypotension predicts the need for an emergent, therapeutic operation in trauma patients who present to the emergency department (ED) with normal systolic blood pressure (SBP). METHODS: An observational, cohort study was conducted at a Level I, urban, county trauma center. Consecutive trauma patients not in cardiopulmonary arrest and transported to the ED by emergency medical services during a one-year period were studied. Data on prehospital and ED vital signs, subsequent hospital course, and surgical procedures were collected. The occurrence of an emergent, therapeutic operation, which was defined based on the types of injuries found or repaired within 6 hours of arrival, was determined from operative and hospital records. RESULTS: Of the 1,227 total trauma patients, 160 were excluded because of cardiopulmonary arrest or inadequate documentation, leaving 1,067 study patients. Of those, 1,028 were normotensive on arrival to the ED. Seventy-one of the 1,028 patients (7%) were hypotensive in the field; 37% of these patients received an emergent, therapeutic operation and 6% died. Of the 1,028 patients, 957 (93%) were normotensive in the field; 11% of these patients received an emergent, therapeutic operation and 3% died. Thus, in trauma patients who were normotensive on arrival to the ED, the need for an emergent, therapeutic operation was more than three times more likely compared with those who had normal SBP in the field (odds ratio 4.5, 95% confidence interval 2.7-7.6). Mortality was also higher in the prehospital hypotension group (odds ratio 2.3, 95% confidence interval 0.8-6.9). CONCLUSION: Prehospital hypotension is a strong predictor of the need for an emergent, therapeutic operation in trauma patients with normal SBP on arrival to the ED.