This week is Patient Safety Awareness Week, an annual education and awareness campaign led by the National Patient Safety Foundation. I did a quick search of articles from our nursing journals to bring you some of the great content we have related to patient safety...

• Creating cultures of safety: Risk management challenges and strategies
• Preoperative communication to improve safety: A literature review
• An overview of error-reduction options
• Cut down on SSIs
• Legal Department: Hand-Off Communication Does Affect Patient Safety
• 10 Organizational Characteristics That May Prevent Falls in Home Healthcare and Hospice
  

Want to read more? We also have an entire collection of resources devoted to the topic of patient safety. In addition to articles and continuing education opportunities, Focus On: Patient Safety includes a PowerPoint presentation on medication error prevention and a quick reference on pressure ulcer prevention. Have a good week!

When I receive a new issue of a journal, I eagerly turn to the editorial right away. I like to feel that connection with the person bringing me the content within the pages (or through the links of online journals.) I find that editorials often tell me more than what is featured in the issue. Oftentimes, editors share their views and opinions on current events, clinical experiences, and sometimes personal stories. I thought I’d share some of my favorite editorials from recent issues here in this “Editorial Round-Up.”

• In Defining a Culture of Safety, OR Nurse2011 editor-in-chief Elizabeth M. Thompson, MSN, RN, CNOR, shares her beliefs about leadership and how a team approach by perioperative nurses has impacted the patient safety movement.
• In Leading Change, Advancing Health, AnneMarie Palatnik, MSN, RN, APN-BC writes “If we don't control our practice, someone else will. If we stay focused on the goal of providing accessible, affordable, quality care, and promoting health, how can we go wrong?”
• In LACE, APRN Consensus... and WIIFM (What's in It for Me)?, Kelly A. Goudreau DSN, RN, ACNS-BC teaches us about the LACE (Licensure, Accreditation, Certification, Education) model and how advanced practice nurses are stakeholders in this regulatory movement.
• In the January issue of Nursing Management, Richard Hader PhD, NE-BC, RN, CHE, CPHQ, FAAN reminds us in Circle Back Before Moving Forward that “No one knows everything and you don't have to either!!”
• In Year of Pain, Year of Promise, Maureen Shawn Kennedy MA, RN  reflects on events of 2010 and looks ahead to 2011 while asking the question “There's a way to move forward, but are we willing?”

This is just a sampling of what our editors are writing about. I hope you enjoy reading them!

In relation to patient care delivery, knowledge can give nurses greater power to take action and lack of knowledge can leave nurses powerless to provide safe or effective care. Evidence of knowledge as a source of power is that many employers during this difficult economic time prefer to recruit experienced RNs rather than incurring the expense of training new graduates.

Anderson and Willson (2009) offer a conceptual framework for nursing knowledge management that supports using technology to offer health care providers many tools to effectively use data to transform it into knowledge. Clinical decision support software such as those integrated with electronic medical records or those that clinicians access through mobile applications (apps) are examples of using data effectively to support knowledgeable clinical interventions. An example of how powerful this can be is that two nurses sharing a clinical rotation have access to texts for purchase in the books store and mobile apps that they can use on a Smartphone. One nurse feels more comfortable using the text and the other is very adept at navigating information technology including mobile apps. The nurse with the mobile product completes medication administration quicker because he finds all the drugs in his reference while the nurse with a book misses out on recent drug releases requiring an extra step to call the pharmacy or to look up drugs online.

There are many other examples and some that may have life-threatening consequences such as drug to drug interactions that information systems recognize that health professionals frequently overlook. In a time when health care quality is a mandate, organizations and professionals who use knowledge effectively will have the power to take control over costs and attain a higher rate of insurance reimbursement due to fewer complications. 

Reference: Anderson, J. A., & Willson, P. (2009). Knowledge Management Organizing Nursing Care Knowledge. Critical Care Nursing Quarterly , 32 (1), 1 - 9.

I can remember a patient with an upper GI bleed, Minnesota tube in place, on maximum vent support and two pressors, who clearly was not doing well. I was checking yet another blood product with a nurse colleague, when a consulting clinician came in and told the family members at the bedside that “his numbers look good.” He then smiled and walked out of the room. The family responded with sighs of relief and “thank goodnesses” while the other nurse and I looked at each other as if to say “what just happened here?”

Have you experienced similar situations? I hesitate to name the clinician’s area of expertise because I don’t want to give any specialty a bad rap or make a generalization. However, the point is that sometimes a person not directly involved with a patient’s day-to-day care can make an observation to patients or families and give them a message that may not be correct. It isn’t always one of false hope either; perhaps a patient is doing better, yet his _______ (you can fill in the blank - rash, glucose level, wound, etc.) is not healing or normalizing and a caregiver might focus on that one clinical finding when talking with the patient and his family members.

It is for this reason that I was both surprised and discouraged when I read the results of a recent study published in Chest, “Effectiveness Trial of an Intensive Communication Structure for Families of Long-Stay ICU Patients.” In this study, 135 ICU patients received ‘usual care’ and 346 ICU patients had weekly family meetings where the patient’s progress and goals were discussed. The investigators were looking at the impact of this intervention on length of stay and no significant difference between the two groups was found.

Despite the negative findings of this study, it is important to remember the positives, or benefits, of sitting down with families for formal meetings where information can be shared and questions can be answered. For example, regular family meetings can allow you to:

• Provide personal contact
• Give updates on the patient’s medical condition and treatment options
• Discuss his prognosis
• Learn about the patient and family, including expectations and wishes
• Gain the opportunity to formulate a trusting and caring relationship
• Tailor the treatment plan according to the input of all staff and the patient’s family.

Please allow me to share the following quote from the authors in their conclusion of this study:

"Even if the use of regular formal family meetings does not alter resource use in all settings, the literature is replete with evidence of other beneficial effects of providing families with time to sit in a quiet location and talk at some length about the patient's goals and preferences and to explore issues related to quality of life, and providing families with consistent support as they face difficult decisions."

What is the standard procedure for initiating, scheduling, and attending family meetings where you work?

Have you ever heard the term complexity compression? I first learned of this term when reading Preserving a positive image of nursing in a complicated healthcare environment. This article caught my eye because although I had never heard the term, I certainly was familiar with the experience. By definition, complexity compression is "what nurses experience when expected to assume additional, unplanned responsibilities while simultaneously conducting their multiple responsibilities in a condensed time frame." Sound familiar? We’ve all been there - having to perform tasks that take us away from direct patient care and having to do more in less time.

It didn’t take long to find the source of this terminology. In 2007, nurse representatives from the Minnesota Nurses Association and faculty from the University Of Minnesota School Of Nursing sought to validate what nurses were experiencing every day - complex patients and complex systems, both with increasing demands. Through the use of focus groups, the researchers identified six major themes that contribute to complexity compression: personal factors, environmental factors, practice factors, systems and technology factors, administration and management factors, and autonomy/control factors.  You can read the published study in its entirety here: Complexity Compression: Nurses Under Fire. 

What's the biggest factor that contributes to complexity compression during your workday?

Reference: Krichbaum, K., Diemert, C., Jacox, L., Jones, A., Koenig, P., Mueller, C., & Disch, J. (2007). Complexity compression: Nurses under fire. Nursing Forum.

During the month of November, two studies came across our newsfeed with regard to hospital admission on weekends. Researchers in the first study, Association between weekend hospital presentation and stroke fatality, published in Neurology on November 2nd, included consecutive patients with acute stroke or transient ischemic attack seen in the emergency department or admitted to the hospital. Of these 20,657 patients, stroke fatality was higher (8.1% vs. 7.0%) with weekend compared to weekday admission.

The second study, Weekend Admissions Predict Higher Mortality in Patients with End Stage Renal Disease, was presented at the American Society of Nephrology's Renal Week 2010. In this retrospective study, 19.7% of the 836,550 estimated admissions with end-stage renal disease were admitted on the weekend. Researchers found that those admitted on the weekend had significantly higher mortality (7.6% vs. 6.6%) than those admitted on a weekday.

A literature search on “weekend hospital admissions” revealed a few more similar studies published over the past 2 years. These included research on patients with acute kidney injury, gastrointestinal hemorrhage, and heart failure. All the studies concluded with similar results; that is, weekend admission is associated with a higher risk for death compared with admission on a weekday. What are the reasons behind this “weekend phenomena?”

Have you ever left after a shift and realized you forgot to relay some important piece of information to the next nurse? It can be tough to organize and prioritize your communication in a timely manner. A structured format or even the use of a template can be helpful; however experience definitely plays a role here too. Like anything else, giving report to an oncoming shift or during any patient hand-off takes practice. A common acronym used to ensure an organized and thorough report is SBAR: Situation, Background, Assessment, and Recommendation.

When I first heard of this method, it seemed too short for me. How could 4 letters/headings be used to convey all the information about my patients after a 12-hour shift? As I learned a little more about SBAR, I realized it was not much different from the method of report I had been using for years.

S= Situation. Include admitting diagnosis, history of present illness, events of hospitalization (Tip: for patients with long hospitalizations, a timeline of events is helpful.) Also, what is the patient’s current situation? Include review of vital signs and events from the past 24 hours.

B= Background. Past medical history, past surgical history, family history, psychosocial history.

A= Assessment. Review of systems. My preferred method of organization has always been neurologic, respiratory, cardiovascular, gastrointestinal, genitourinary, hematologic/immunologic, and endocrine systems; skin; laboratory values and diagnostic findings; medications; psychosocial issues.

R= Recommendation.  Include anything that needs ongoing or further attention.

What method of report works best for you?

As I mentioned in a previous post , one of the most stressful things I experienced in nursing school was memorizing all of the drug information. I can remember preparing for clinical the night before with medication lists for my two patients, a drug reference book by my side, a stack of index cards, pencils, and various color highlighters. The lists would be long as if my instructor picked out my patient assignment solely based on the number of meds I would be administering and it never failed that my patients’ medication lists had no overlap. For example, it seemed that even if both were cardiac patients with a history of hypertension, one was on a diuretic and the other on an ACE inhibitor! The joke was usually on me though, for no matter how well I memorized the drug names, indications, dosages, side effects, and interactions, there were always one or two drug orders that were changed by the time I arrived for clinical. Of course, those newly ordered medications would be the ones my instructor asked me about!  Ahhh…the joys of nursing school!

I had heard a lot about the “reality shock” of starting out as a new RN. I knew I would not be able to research my patients the night before and learn all about their medications ahead of time. How would I manage medication administration? Would I deliver them safely and be alert for every potential side effect? Would I make an error?

One of my most important nursing tools when I was a new graduate was a drug handbook that my preceptor gave me. She advised me to highlight in it, mark pages, take notes, and do anything else to it that made it easier for me to safely administer medications. Through the years I bought new editions but I continued to use it in the same manner as that first book.

It is now easier than ever to access drug information. The internet allows us to get any information within seconds. However, it is so important to make sure the information you are accessing is accurate and up-to-date.

Oftentimes, prescribing information can be found on the pharmaceutical company websites or by searching FDA approved drug products. For safety information, the FDA’s Drug Safety Labeling Changes and the Institute for Safe Medication Practices are good sites to add to your favorites. Also, be sure to check out drug updates here on NursingCenter. We’ll keep you informed about drug news, medication errors, and the latest drug-related articles and CEs that publish in our journals. What resources do you use?

During Patient Safety Awareness Week last week, the following interview from the New York Times caught my attention. In Doctor Leads Quest for Safer Ways to Care for Patients, Dr. Peter J. Pronovost, medical director of the Quality and Safety Research Group at Johns Hopkins Hospital in Baltimore, describes his quest for patient safety after the misdiagnosis of his father and the death of a child from a catheter-associated infection.

At one point in the interview, Dr. Pronovost talks about improving physician handwashing practices. Part of the solution was for the nursing staff to make sure the doctors wash their hands and if the doctors didn’t wash, the nurse could stop the procedure. The following excerpt from the interview demonstrates how both the nurses and doctors responded:

Q. HOW DID THAT FLY?
A. You would have thought I started World War III! The nurses said it wasn’t their  job to monitor doctors; the doctors said no nurse was going to stop takeoff. I said: “Doctors, we know we’re not perfect, and we can forget important safety measures.  And nurses, how could you permit a doctor to start if they haven’t washed their hands?” I told the nurses they could page me day or night, and I’d support them.  Well, in four years’ time, we’ve gotten infection rates down to almost zero in the  I.C.U.

Wonderful outcome, right? Yes, but the strategy was not well-accepted initially. Later in the interview, Dr. Pronovost discusses the benefits of empowering nurses and avoiding the hierarchical structure seen in so many settings. As nurses, we spend the most time with patients, we are aware of subtle changes in their condition, and we have a duty to speak up when patient safety is at risk. Along the same lines, we also have the right to be heard. In short, to have a successful team, mutual respect and effective communication are critical.

How comfortable are you with your team? What approach would you take in reminding a colleague (nurse, physician, or anyone else) to wash his or her hands?

When I hear the words “patient safety”, the first thing that comes to my mind is medication errors. Of course, there are plenty more factors to consider with regard to patient safety – infections, surgical errors, and pressure ulcers, just to name a few. In fact, a search for the keywords “patient safety” on nursingcenter.com yields a result of 3,309 articles!

This week is Patient Safety Awareness Week. The theme, "Let's Talk: Healthy Conversations for Safer Healthcare" got me thinking about how conversation can minimize or prevent medication errors. Here are some of my ideas – please add to this list! Let’s learn from each other and help one another to improve patient safety!

Questions to ask patients:
1. What medications do you take regularly? How do you take them? When do you take them? With meals or on an empty stomach? Why do you take these medications? Do you ever not take them?
2. Do you take any medications “as needed”? What medications? Why do you take them?
3. Do you take any over-the-counter medications? What are they? Why do you take them? When do you take them?
4. Do you take and herbs or vitamins? When? How? Why?
5. Do you have any questions about your medication regimen?
6. Is there anything I can do to help you manage your medication routine?

Before administering a medication, ask him if he’s had this drug before, if he knows why it’s been prescribed for him, if the dose is his usual dose, and if he has any questions.

For discussion with our colleagues:
1. Let’s review his medication list.
2. How often did you give his pain medication (or any p.r.n. medication)? What were the results?

Also, if any questions arise at any time – talk about it! Confer with your nurse colleagues, pharmacist, and the prescriber. The patient and his family members or other caregivers can also be valuable sources of information.

Lastly, be sure to take a look at the website of the Institute for Safe Medication Practices (ISMP). Here you’ll find several must-have tools for nurses, including a ISMP’s list of high-alert medications, ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations, Oral Dosage Forms that should not be crushed, and more. 

Thanks for “listening” to me. What do you want to talk about?