Patient Safety Commons^™

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 …

Staff Responses When Parents Hit Children In A Hospital Setting., Sarah A. Font, Elizabeth T. Gershoff, Catherine A. Taylor, Amy Terreros, Monica Nielsen-Parker, Lisa Spector, Rebecca H. Foster, Ann Budzak Garza, Denyse Olson-Dorff

Manuscripts, Articles, Book Chapters and Other Papers

OBJECTIVE: Physical punishment of children is a prevalent practice that is condemned by most medical professionals given its link with increased risk of child physical abuse and other adverse child outcomes. This study examined the prevalence of parent-to-child hitting in medical settings and the intervention behaviors of staff who witness it.

METHOD: Staff at a children's medical center and a general medical center completed a voluntary, anonymous survey. We used descriptive statistics to examine differences in the experiences of physicians, nurses, and other medical staff. We used logistic regression to predict intervention behaviors among staff who witnessed parent-to-child hitting.

RESULTS: …

Risk Factors For Sleep-Related Infant Deaths In In-Home And Out-Of-Home Settings., Hilina Kassa, Rachel Y. Moon, Jeffrey D. Colvin

Manuscripts, Articles, Book Chapters and Other Papers

Background and objective: Multiple environmental risk factors are associated with sleep-related infant deaths. Little is known about differences in risk factors for deaths occurring in-home and out-of-home. We sought to compare risk factors for in-home and out-of-home infant deaths.

Methods: We conducted a cross-sectional analysis of sleep-related infant deaths from 2004 to 2014 in the National Child Fatality Review and Prevention database. The main exposure was setting (in-home versus out-of-home) at time of death. Primary outcomes were known risk factors: sleep position, sleep location (eg, crib), objects in the environment, and bed sharing. Risk factors for in-home versus out-of-home deaths …

A Pressure Ulcer And Fall Rate Quality Composite Index For Acute Care Units: A Measure Development Study., Diane K. Boyle, Ananda Jayawardhana, Mary E. Burman, Nancy E. Dunton, Vincent S. Staggs, Sandra Bergquist-Beringer, Byron J. Gajewski

Manuscripts, Articles, Book Chapters and Other Papers

Background: Composite indices are single measures that combine the strengths of two or more individual measures and provide broader, easy-to-use measures for evaluation of provider performance and comparisons across units and hospitals to support quality improvement.

Objective: The study objective was to develop a unit-level inpatient composite nursing care quality performance index-the Pressure Ulcer and Fall Rate Quality Composite Index.

Design: Two-phase measure development study.

Settings: 5144 patient care units in 857 United States hospitals participating in the National Database of Nursing Quality Indictors® during the year 2013.

Methods: The Pressure Ulcer and Fall Rate Quality Composite Index was developed …

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 …

Summer Dehydration, Rodney Richmond

Faculty Research ​and Publications

No abstract provided.

Realizing Improved Patient Care Through Human-Centered Design In The Operating Room, Volume 2, Clemson Center For Health Facilities Design & Testing

Center for Health Facilities Design and Testing

This 4-year grant from the Agency for Healthcare Research and Quality supports the development of a learning lab focused on designing a safer, more ergonomic operating room. Sponsor: Agency for Healthcare Research Quality Project period: 9/1/15 to 8/31/19 Project Description: The overarching goal of the learning lab titled, “Realizing Improved Patient Care through Human-Centered Design in the Operating Room (RIPCHD.OR) is to develop an evidence-based framework and methodology for the design and operation of operating rooms such that it impacts improved perioperative outcomes including surgical site infections, surgical errors and staff injuries.

Impact Of Electronic Health Records On Patient Outcomes, Lilian Ndifon, Jude E. Edwards, Leila Halawi

Publications

With the passing of the HITECH Act, EHRs have come into prominence and sharper focus, due to efforts by the government to push for a national adoption of EHRs into our healthcare system. This push for a national adoption of EHRs is based on the premise that it will help improve the quality delivery of health care services and reduce costs. However, this push for a “national adoption” has experienced mixed results. This study was designed to assess the impact of EHRs post-2009, the year of the HITECH Act, to review some of the key contributing factors to this mixed …

Slug Bug: Quality Improvement With Orchestrated Testing Leads To Nicu Clabsi Reduction., Anthony J. Piazza, Beverly Brozanski, Lloyd Provost, Theresa R. Grover, John Chuo, Joan R. Smith, Teresa Mingrone, Susan Moran, Lorna Morelli, Isabella Zaniletti, Eugenia K. Pallotto

Manuscripts, Articles, Book Chapters and Other Papers

OBJECTIVE: Reduce central line-associated bloodstream infection (CLABSI) rates 15% over 12 months in children's hospital NICUs. Use orchestrated testing as an approach to identify important CLABSI prevention practices.

METHODS: Literature review, expert opinion, and benchmarking were used to develop clinical practice recommendations for central line care. Four existing CLABSI prevention strategies (tubing change technique, hub care monitoring, central venous catheter access limitation, and central venous catheter removal monitoring) were identified for study. We compared the change in CLABSI rates from baseline throughout the study period in 17 participating centers. Using orchestrated testing, centers were then placed into 1 of 8 …

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 …

Hypertension Patient Compliance, Taylor Myers

University Honors Program

Hypertension is a prevalent condition in the United States that often has many comorbidities. It is usually asymptomatic, so patients are less likely to comply with treatment if they feel healthy. This is a growing concern due to the complications that can arise from hypertension. Hypertension can be associated with a lower quality of life in patients that have symptoms. However, in patients that do not show symptoms they may feel that they have a higher quality of life by not changing their preexisting habits. The reasons for patient noncompliance will be studied as well as interventions to increase compliance, …

Medicine Cabinets: The New Drug Dealers, Rodney Richmond

Faculty Research ​and Publications

No abstract provided.

Realizing Improved Patient Care Through Human-Centered Design In The Operating Room, Volume 1, Clemson Center For Health Facilities Design & Testing

Center for Health Facilities Design and Testing

This 4-year grant from the Agency for Healthcare Research and Quality supports the development of a learning lab focused on designing a safer, more ergonomic operating room. Sponsor: Agency Agency for Healthcare Research Quality Project period: 9/1/15 to 8/31/19 Project Description: The overarching goal of the learning lab titled “Realizing Improved Patient Care through Human-Centered Design in the Operating Room (RIPCHD.OR) is to develop an evidence-based framework and methodology for the design and operation of operating rooms such that it impacts improved perioperative outcomes including surgical site infections, surgical errors and staff injuries.

Patient Safety Culture And High Reliability Organizations, Jared D. Padgett

Walden Dissertations and Doctoral Studies

A 1999 evaluation of case studies performed by staff from the Institute of Medicine found that between 40,000 and 98,000 patients died from preventable errors, while 43,598 individuals died in car accidents that year. A 2011 report increased that estimate nearly 10 times. Widespread preventable patient harm still occurs despite an increase in healthcare regulations. High-reliability organization theory has contributed to improved safety and may potentially reverse this trend. This explorative single case study explored how the perceptions and experiences of nursing and respiratory staff affected the successful transition of a healthcare organization into a reliability-seeking organization. Fourteen participants from …

Hot Yoga Establishments In Local Communities Serving Pregnant Women: A Pilot Study On The Health Implications Of Its Practice And Environmental Conditions, Viann N. Nguyen-Feng, Steven L. Feng, Shilpa Babbar, Nicole Calloway Rankins, James D. Blando

Community & Environmental Health Faculty Publications

Hot yoga establishments have been increasing in popularity in local communities. Studios may support participation among pregnant women though no clinical studies currently exist that examine prenatal hot yoga effects. The pilot study described in this article aimed to assess the spread of prenatal hot yoga and to provide information on the environmental conditions and practices of those who engage in hot yoga within a local community. A thermal environment meter was used to measure ambient air conditions during three 90-minute hot yoga classes. Mothers who practiced prenatal hot yoga were more likely than non-hot yoga practitioners to have someone …

Uncovering The Silent Victims Of The American Medical Liability System, Joanna Shepherd

Faculty Articles

A frequently overlooked problem with the current medical liability system is the vast number of medical errors that go uncompensated. Although studies indicate that 1% of hospital patients are victims of medical negligence, fewer than 2% of these injured patients file claims. In this Article, I explain that many victims of medical malpractice do not file claims because they are unable to find attorneys willing to take their cases.

I conducted the first national survey of attorneys to explore medical malpractice victims' access to the civil justice system. The results from the survey indicate that the economic reality of litigation …

Situational Awareness/Triage Tool For Use In A Chemical, Biological, Radiological Nuclear Explosive (Cbrne) Environment, John N. Scarlett, Heather L. Gallup, David A. Smith

AFIT Patents

A method of managing patient care and emergency response following a Chemical, Biological, Radiological, or Nuclear Explosive (CBRNE) attack and maintaining compliance with the Health Insurance Portability and Accountability Act (HIPAA). The method including identifying each patient with a unique patient identifier, the identifier based upon the geospatial location of the patient, the geospatial location including at least the latitude and longitude of the patient when first treated, the unique patient identifier being part of patient data. Providing a collection point of patient data to form a patient data database where in the patient location data may be used to …

Empowerment-Based Positive Youth Development: A New Understanding Of Healthy Development For African American Youth, Raphael Travis Jr., Tamara Leech

Department of Public Health Scholarship and Creative Works

A shift occurred in research about adolescents in the general population. Research is moving away from deficits toward a resilience paradigm and understanding trajectories of positive youth development. This shift has been less consistent in research and practice with African American youth. A gap also exists in understanding whether individual youth development dimensions generate potential in other dimensions. This study presents an empowerment-based positive youth development model. It builds upon existing research to present a new vision of healthy development for African American youth that is strengths-based, developmental, culture-bound, and action-oriented. It emphasizes the relationship between person and environment, the …

"Mercy Tape" Unveiled: Provides Better Weight Estimates For Children, Bill Van Kirk

Our Story Continues

Susan Abdel-Rahman, Pharm.D, Clinical Pharmacology and Medical Toxicology, led the Children's Mercy research team that developed the Mercy TAPE, a new device to estimate the weight of pediatric patients ages two months to 16 years.

Accurate weight estimates in resource-restricted settings (lacking the means to weigh a child) are important because they are used to determine appropriate medication dosage, fluid volumes for resuscitation, breathing tube sizes, and more.

Patient Understanding Of Coordinated Medical Treatment Success Within The Minnesota Medical Home Model: An Exploratory Qualitative Inquiry, Jeremy F. Stockinger

Theses and Dissertations

The US health care system is often described as a complex, fragmented system where patients experience less access, coordinated, and comprehensive care that is ultimately more costly (Rosenberg, 2009). The problem addressed in this study was to understand coordinated medical treatment in the medical home model from the patient perspective. This study provides the opportunity to increase the understanding of the factors affecting coordinated medical treatment success.