Patient Safety Commons^™

A Case For Delirium Risk Prediction Models To Aid In Triaging Resources To Those Most At Risk An Integrative Literature Review, Tammy Perttula

Nursing Masters Papers

Abstract

Delirium is a complex syndrome resulting from compounding effects of acute illness, comorbidities, and the environment. It results in adverse outcomes: elevated mortality rates, length of stay, readmissions, institutionalization, long-term cognitive changes, and diminished quality of life. The rate of iatrogenic delirium is astounding, ranging from 10%-89%. There are no curative treatments; thus, primary prevention is the key. The purpose of this literature review is to identify and critique the research for the accuracy of risk stratification and feasibility in practice. Support for interventions that prevent delirium is mounting; however, interventions are resource-intensive and often not implemented. Researchers have …

Investigating The Impact Of The Nursing Practice Environment (Npe) On Central Line-Associated Bloodstream Infections (Clabsi) Among Older Adults In The Intensive Care Unit (Icu), Kristen A. Cribbs

Dissertations and Theses

Background: Health care–associated infections, resulting from treatment received for medical or surgical conditions in a health care setting, represent a critical public health and patient safety issue, exacting substantial medical, social, and economic costs. The costliest among the leading causes of preventable health care-associated infections is central-line associated bloodstream infections (CLABSI), to which older adults (age 65 years and older) are particularly susceptible, especially during intensive care unit (ICU) stays. A rich body of research has empirically linked the quality of the nursing practice environment (NPE) in hospitals to both positive and negative patient outcomes; yet, surprisingly few studies have …

Effects Of Shift Length On Nursing Staff’S Productivity, Safety, And Well-Being, Victoria Sivesind

Nursing | Senior Theses

In this thesis the relationship between normal shift length for nurses and fatigue, burnout, intention to leave job, and patient outcomes and satisfaction. A review of literature has been done and conclusions have been made about the previous research reviewed in the thesis. A proposal for further research has been included and details how the author plans to provide further clarification to the questions at hand in order to better clinical nursing practice for the future. The proposed study includes sending out a survey to members of the Sigma Theta Tau Honors Nursing Society. It will inquire about shift length, …

J Mich Dent Assoc February 2020

The Journal of the Michigan Dental Association

Every month,The Journal of the Michigan Dental Association brings news, information, and features about Michigan dentistry to our state's oral health community and the MDA's 6,200+ members. No publication reaches more Michigan dentists!

In this issue, the reader will find the following original content:

• A cover story on the 2020 MDA Annual Session
• A feature covering student perspectives on the Opioid Crisis
• News you need, Editorial and regular department articles on MDA Foundation activities, Dentistry and the Law, Staff Matters, Headquarters Report, and component news

This issue also includes articles reprinted with permission:

• “Muscle Deprogramming: A Source of Confusion”, …

Just Culture: It's More Than Policy, Linda Paradiso, Nancy Sweeney

Ellmer School of Nursing Faculty Publications

[Description] Paradiso and Sweeney discuss the relationship between trust, just culture, and error reporting in medical care. Errors rarely occur in a vacuum, rather they're a sequence of events with multiple opportunities for correction. Clinical nurses can have a significant impact on reducing errors due to their proximity to patients. Just culture is a safe haven that supports reporting. In a just culture environment, organizations are accountable for systems they design and analysis of the incident, not the individual. The shift to a just culture is a slow process that takes years to develop and hardwire. Hospital-wide policies that incorporate …

Law, Technology And Patient Safety, Kathryn Zeiler, Gregory Hardy

Faculty Scholarship

Medical error is the third leading cause of death in the United States, In an effort to increase patient safety, various regulatory agencies require reporting of adverse events, but reported counts tend to be inaccurate. In 2005, in an effort to reduce adverse event rates, Congress proposed a list of “never events,” adverse events, such as wrong-site surgery, that should never occur in hospitals, and authorized CMS to refuse payment for care required following such events. CMS has since pushed for further regulation, “such as putting more payment at risk, increasing transparency, increasing frequency of quality data reviews, and stepping …

Improving Bedside Procedural Safety Through Optimizing Timeout Documentation And A Pre-Procedure Checklist, Jennifer Harris, Md, R. Benson Jones, Md, Kristin Lohr, Md, Grant Turner, Md, Drew Kotler, Md, Justine Blum, Md, Megan Margiotta, Md, Matthew Bokhari, Md, Erica Li, Md, Riti Kanesa-Thasan, Md, Bracken Babula, Md, Rebecca Jaffe, Md

Department of Medicine Posters

Aim

GOAL: Improve the safety of patients undergoing bedside procedures while maintaining the full spectrum of graduated autonomy in procedure training for residents.

SMART Aim: Increase the rate of timeouts documented for bedside procedures from 29% to 50% by June 2018.

Self-Efficacy In Situation Background Assessment And Recommendation Communication Using Information Technology In Baccalaureate Nursing, Kelly Etcheberry Espinoza

UNLV Theses, Dissertations, Professional Papers, and Capstones

Strong communication skills are essential in establishing a foundation for safe delivery of care. A report from the Institute of Medicine (IOM) titled: To Err is Human: Building a Safer Health System estimated 44,000 to 98,000 deaths occur due to medical errors annually. Communication failure was found to be the root cause in 70% of these cases of medical error. Several studies also indicate communication issues still represent up to 80% of errors and sentinel events in hospitals accredited by the Joint Commission. The IOM's report indicate improving communication in the healthcare setting is essential in reducing medical errors.

In …

Reliability Of Pressure Ulcer Rates: How Precisely Can We Differentiate Among Hospital Units, And Does The Standard Signal-Noise Reliability Measure Reflect This Precision?, Vincent S. Staggs, Emily Cramer

Manuscripts, Articles, Book Chapters and Other Papers

Hospital performance reports often include rankings of unit pressure ulcer rates. Differentiating among units on the basis of quality requires reliable measurement. Our objectives were to describe and apply methods for assessing reliability of hospital-acquired pressure ulcer rates and evaluate a standard signal-noise reliability measure as an indicator of precision of differentiation among units. Quarterly pressure ulcer data from 8,199 critical care, step-down, medical, surgical, and medical-surgical nursing units from 1,299 US hospitals were analyzed. Using beta-binomial models, we estimated between-unit variability (signal) and within-unit variability (noise) in annual unit pressure ulcer rates. Signal-noise reliability was computed as the ratio …

Nurse Staffing And Patient Outcomes: A Longitudinal Study On Trend And Seasonality., Jianghua He, Vincent S. Staggs, Sandra Bergquist-Beringer, Nancy Dunton

Manuscripts, Articles, Book Chapters and Other Papers

BACKGROUND: Time trends and seasonal patterns have been observed in nurse staffing and nursing-sensitive patient outcomes in recent years. It is unknown whether these changes were associated.

METHODS: Quarterly unit-level nursing data in 2004-2012 were extracted from the National Database of Nursing Quality Indicators® (NDNQI®). Units were divided into groups based on patterns of missing data. All variables were aggregated across units within these groups and analyses were conducted at the group level. Patient outcomes included rates of inpatient falls and hospital-acquired pressure ulcers. Staffing variables included total nursing hours per patient days (HPPD) and percent of nursing hours provided …

Simulation-Based Training For Patient Safety: 10 Principles That Matter, Eduardo Salas, Katherine A. Wilson, Elizabeth Lazzara, Heidi B. King, Jeffery S. Augenstein

Publications

Simulation-based training can improve patient care when factors influencing its design, delivery, evaluation, and transfer are taken into consideration. In this paper, we provide a number of principles and practical tips that organizations in health care can use to begin implementing effective simulation-based training as a way to enhance patient safety. We commend the health care community for their efforts thus far. We hope that the information provided in this paper will encourage thinking beyond the "bells and whistles" of the simulation and bring to light full potential of simulation-based training in health care and patient safety.