A Place for the Professional Introduction in Practice.

This article describes a survey exploring the use of professional introductions by nurses.For this project, a survey inquiring about introduction practices was administered to nurses attending a regional research conference.

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.

Clinical Practice Guideline: Safe Medication Use in the ICU.

OBJECTIVE: To provide ICU clinicians with evidence-based guidance on safe medication use practices for the critically ill. DATA SOURCES: PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, Scopus, and ISI Web of Science for relevant material to December 2015. STUDY SELECTION: Based on three key components: 1) environment and patients, 2) the medication use process, and 3) the patient safety surveillance system. The committee collectively developed Population, Intervention, Comparator, Outcome questions and quality of evidence statements pertaining to medication errors and adverse drug events addressing the key components. A total of 34 Population, Intervention, Comparator, Outcome questions, five quality of evidence statements, and one commentary on disclosure was developed. DATA EXTRACTION: Subcommittee members were assigned selected Population, Intervention, Comparator, Outcome questions or quality of evidence statements. Subcommittee members completed their Grading of Recommendations Assessment, Development, and Evaluation of the question with his/her quality of evidence assessment and proposed strength of recommendation, then the draft was reviewed by the relevant subcommittee. The subcommittee collectively reviewed the evidence profiles for each question they developed. After the draft was discussed and approved by the entire committee, then the document was circulated among all members for voting on the quality of evidence and strength of recommendation. DATA SYNTHESIS: The committee followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation system to determine quality of evidence and strength of recommendations. CONCLUSIONS: This guideline evaluates the ICU environment as a risk for medication-related events and the environmental changes that are possible to improve safe medication use. Prevention strategies for medication-related events are reviewed by medication use process node (prescribing, distribution, administration, monitoring). Detailed considerations to an active surveillance system that includes reporting, identification, and evaluation are discussed. Also, highlighted is the need for future research for safe medication practices that is specific to critically ill patients.

Development of a checklist for documenting team and collaborative behaviors during multidisciplinary bedside rounds.

OBJECTIVE: The objective of this study was to develop a reliable and valid checklist for documenting team and collaborative behaviors occurring during multidisciplinary bedside rounds. BACKGROUND: Teamwork and collaboration are important for providing high-quality patient care, yet there are no objective means of evaluating the occurrence of team and collaborative behaviors during bedside rounds. METHODS: A checklist was developed and tested on 3 general medical units. Items on the checklist were derived from the literature and our medical center's patient-family-centered values. RESULTS: The final version of the checklist was determined to be reliable, valid, and easy to use in the clinical setting. CONCLUSION: Clinicians, administrators, and investigators are encouraged to use and/or modify this checklist for use in their setting. Further research identifying instruments to objectively measure teamwork and collaboration is needed.

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.

How much teamwork exists between nurses and junior doctors in the intensive care unit?

AIMS: The aim of this study was to measure the degree of similarity of attitudes on collaboration between nurses and junior doctors (known as residents in the United States) in the ICU. BACKGROUND: Existing research shows that nurses and physicians view the amount of teamwork they experience in the ICU differently though the attitudes of junior doctors and critical care nurses on collaboration remain unknown. METHODS: Thirty-one nurses and 46 junior doctors completed a modified version of the Baggs Collaboration and Satisfaction about Care Decisions instrument during 2006-2007 in a 24 bed medical/surgical ICU in the northeastern United States. Score responses of nurses and junior doctors were compared with the Wilcoxon (Mann-Whitney) rank-sum test. RESULTS/FINDINGS: Nurses consistently gave more negative responses on every survey question than junior doctors. While nurses said that the amount of collaboration was inadequate, junior doctors were satisfied and views between groups were most divergent (P < 0.01) on questions about overall satisfaction with team decisions. CONCLUSIONS: Nurses and junior doctors held very different views on the amount of collaborative teamwork that occurs in the ICU. Junior doctors' views are similar to those of more experienced physicians observed in previous studies.

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.

Survey of Nurses' Experiences Applying The Joint Commission's Medication Management Titration Standards.

BACKGROUND: Critical care nurses titrate continuous infusions of medications to achieve clinical end points. In 2017, The Joint Commission (TJC) placed restrictions on titration practice, decreasing nurses' autonomous decision-making. OBJECTIVES: To describe the practice and perceptions of nurses regarding the 2017 TJC accreditation/regulatory standards for titration of continuous medication infusions. METHODS: A survey of nurses' experiences titrating continuous medication infusions was developed, validated, and distributed electronically to members of the American Association of Critical-Care Nurses. RESULTS: The content validity index for the survey was 1.0 for relevance and 0.95 for clarity. A total of 781 nurses completed the survey; 625 (80%) perceived titration standards to cause delays in patient care, and 726 (93%) experienced moral distress (mean [SD], 4.97 [2.67]; scale, 0-10). Among respondents, 33% could not comply with titration orders, 68% reported suboptimal care resulting from pressure to comply with orders, 70% deviated from orders to meet patient needs, and 84% requested revised orders to ensure compliance. Suboptimal care and delays in care significantly and strongly (regression coefficients ≥0.69) predicted moral distress. CONCLUSIONS: Critical care nurses perceive TJC medication titration standards to adversely impact patient care and contribute to moral distress. The improved 2020 updates to the standards do not address delays and inability to comply with orders, leading to moral distress. Advocacy is indicated in order to mitigate unintended consequences of TJC medication management titration standards.

Nursing implications for prevention of adverse drug events in the intensive care unit.

Adverse drug events are common in the intensive care unit setting. Despite the existence of many long-standing safety principles (such as the "five rights") and new mechanisms to promote medication safety, there is still a gap between practice and the goal of patient safety. This is the result of the many human and system factors that impact care delivery. Research supports the role of the nurse as having a positive impact on patient outcomes. Future research requires the evaluation of new strategies and technologies to support safe medication administration. For example, patient simulation is being used to teach student and novice nurses principles of medication administration in a "safe" setting that more closely resembles the clinical environment. The Institute of Nursing repeatedly has stressed the need to address the organizational, technical, and human issues that impact patient safety, with an emphasis on the need to transform the nurse work environment to keep patients safe. This transformation will require a new level of interdisciplinary research and nursing involvement to address better care for our patients and, in particular, reduce adverse drug events.

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 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.

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.

Feasibility of family participation in a delirium prevention program for hospitalized older adults.

Delirium is the leading complication of hospitalization for older adults. The role family caregivers could play in delirium prevention and how nurses could facilitate family participation has been largely unexplored. This study examined the feasibility of family participation in a multicomponent intervention program for delirium prevention in hospitalized older adults called Family-HELP, as an adaptation and extension of the Hospital Elder Life Program (HELP). Family-HELP demonstrates that active engagement of family caregivers in preventive interventions for delirium is feasible. Intervention completion occurred at least 55% of the time. Three themes emerged on barriers and facilitators for family participation: therapeutic relationships, partnership, and environment. Key to successful implementation of the program is attention to the identified barriers and facilitators. These findings have implications for clinicians committed to delivering quality inpatient care to older adults and their families, with the benefits of HELP being extended to include family caregivers with an important role in delirium prevention efforts.

Use of a Transfusion Checklist by Student Nurses to Improve Patient Safety.

Better education around the recognition of transfusion-associated adverse events is warranted. It is unknown if checklist use improves recognition by student nurses. This study examined whether using a checklist could improve transfusion-associated adverse event recognition behaviors. There was an increased frequency of transfusion-associated adverse event management behaviors in the checklist group, but overall recognition was no greater than other groups. A transfusion-associated adverse event checklist may increase patient safety by promoting identification behaviors.

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.

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.

Human patient simulation: teaching students to provide safe care.

The use of human patient simulation as a teaching methodology for nursing students has become popular. Using human patient simulation effectively demands paying careful attention to the details of the simulation, debriefing, and evaluation processes. Our experience in designing simulation experiences and evaluating student behaviors confirms the resource-intensive nature of human patient simulation and the need for clear, measurable objectives. When used properly, human patient simulation offers a unique opportunity to teach nursing students important patient safety principles.