Blame--Do You Know It When You See It?

The landmark Institute of Medicine Report, To Err Is Human: Building a Safer Health Care System. stated that medical error causes 44,000 to 98,000 deaths per year. There is no question that the report raised awareness of patient safety and stressed the importance of patient outcomes. Heightened awareness has produced a patient safety industry of sorts, with solutions that range from technology to outcomes measurement. Regulatory bodies, such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), have recognized the need for patient safety to be embedded in the culture of healthcare organizations. In particular, the JCAHO has encouraged use of the root cause analysis process for investigating near miss and adverse events. This process emphasizes learning from system analysis over assigning individual blame, an approach used successfully in such high reliability organizations as the aviation industry and the military. Many healthcare organizations have formulated nonpunitive reporting policies to encourage error reporting and to identify systems issues. This article discusses the importance of a work complexity and human factors focus, how blame will continue to surface as patient safety efforts are implemented, and implications for outcomes management

Voices of chief nursing executives informing a doctor of nursing practice program

The purpose of this article is to describe the business case framework used to guide doctor of nursing practice (DNP) program enhancements and to discuss methods used to gain chief nurse executives' (CNEs) perspectives for desired curricular and experiential content for doctor of nursing practice nurses in health care system executive roles. Principal results of CNE interview responses were closely aligned to the knowledge, skills and/or attitudes identified by the national leadership organizations. Major conclusions of this article are that curriculum change should include increased emphasis on leadership, implementation science, and translation of evidence into practice methods. Business, information and technology management, policy, and health care law content would also need to be re-balanced to facilitate DNP graduates' health care system level practice

Bedside Interprofessional Rounding: The View From the Patient's Side of the Bed

BACKGROUND: Bedside interprofessional rounding is gaining ground as a means to improve collaboration and patient outcomes, yet little is known regarding patients' perceptions of the practice. METHODS: This descriptive study used individual patient interviews to elicit views on interprofessional rounding from 35 patients at a large, urban hospital. RESULTS: The findings identified three major categories: 1) about the rounding process; 2) clinical information; and 3) the impact/value of bedside inter-professional rounding. DISCUSSION: Intentionally eliciting and responding to our patients' views of interprofessional rounding may help us design methods that are patient centered and effective

Lessons Learned: Nurses’ Experiences with Errors in Nursing

Background Health care organizations seek to maximize the reporting of medical errors to improve patient safety. Purpose This study explored licensed nurses' decision-making with regard to reporting medical errors. Methods Grounded theory methods guided the study. Thirty nurses from adult intensive care units were interviewed, and qualitative analysis was used to develop a theoretical framework based on their narratives. Discussion The theoretical model was titled “Learning Lessons from the Error.” The concept of learning lessons was central to the theoretical model. The model included five stages: Being Off-Kilter, Living the Error, Reporting or Telling About the Error, Living the Aftermath, and Lurking in Your Mind. Conclusion This study illuminates the unique experiences of licensed nurses who have made medical errors. The findings can inform initiatives to improve error reporting and to support nurses who have made errors

The Power of Collaboration With Patient Safety Programs: Building Safe Passage for Patients, Nurses, and Clinical Staff

Patient safety is a relatively new field, with many opinions and few effectively proven approaches. One factor is clear: optimal patient safety outcomes cannot be achieved in isolation. Although it is well recognized that multidisciplinary collaboration in the healthcare setting is necessary to effect patient safety, collaboration with resources external to healthcare-academia and industry in particular-will not only aid but also quicken the patient safety efforts. The authors outline a healthcare system\u27s use of all available resources to build a patient safety program

Outcomes of Adding Patient and Family Engagement Education to Fall Prevention Bundled Interventions.

Nurses strive to reduce risk and ensure patient safety from falls in health care systems. Patients and their families are able to take a more active role in reducing falls. The focus of this article is on the use of bundled fall prevention interventions highlighted by a patient/family engagement educational video. The implementation of this quality improvement intervention across 2 different patient populations was successful in achieving unit benchmarks

“Anybody on this list that you're more worried about?” Qualitative analysis exploring the functions of questions during end of shift handoffs

Background Shift change handoffs are known to be a point of vulnerability in the quality, safety and outcomes of healthcare. Despite numerous efforts to improve handoff reliability, few interventions have produced lasting change. Although the opportunity to ask questions during patient handoff has been required by some regulatory bodies, the function of questions during handoff has been less well explored and understood. Objective To investigate questions and the functions they serve in nursing and medicine handoffs. Research design Qualitative thematic analysis based on audio recordings of nurse-to-nurse, medical resident-to-resident and surgical intern-to-intern handoffs. Subjects Twenty-seven nurse handoff dyads and 18 medical resident and surgical intern handoff dyads at one VA Medical Center. Results Our analysis revealed that the vast majority of questions were asked by the Incoming Providers. Although topics varied widely, the bulk of Incoming Provider questions requested information that would best help them understand individual patient conditions and plan accordingly. Other question types sought consensus on clinical reasoning or framing and alignment between the two professionals. Conclusions Handoffs are a type of socially constructed work. Questions emerge with some frequency in virtually all handoffs but not in a linear or predictable way. Instead, they arise in the moment, as necessary, and without preplanning. A checklist cannot model this process element because it is a static memory aid and questions occur in a relational context that is emergent. Studying the different functions of questions during end of shift handoffs provides insights into the interface between the technical context in which information is transferred and the social context in which meaning is created

The Power of Collaboration with Patient Safety Programs

Patient safety is a relatively new field, with many options and few effectively proven approaches. One factor is clear: optimal patient safety outcomes cannot be achieved in isolation. Although it is well recognized that multidisciplinary collaboration in the healthcare setting is necessry to effect patient safety, collaboration with resources external to healthcare- academia and industry in particular - will not only aid but also quicken the patient safety efforts

How Staff RNs Perceive Nurse Manager Roles

Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Purpose: Nurse managers ’ behaviors and job satisfaction are commonly addressed in the literature; however, registered nurse perceptions of nurse manager behaviors provide a unique perspective that may inform future strategies designed to enhance RN job satisfaction. The purpose of this study was to assess the perceptions of registered nurses that were explored through focus groups to learn the behaviors of nurse managers that most influence registered nurse’s job satisfaction. Methods: Five focus groups were conducted through semi-structured interviews of a total of 28 RNs to provide data that were coded through qualitative content analysis for themes. Findings: The findings provide nurse managers with data related to the perceptions of RNs and the behaviors of managers that influence job satisfaction. In relation to the focus group’s discussions, a disconnection was identified between the perceptions of the RNs regarding their actual work issues and the nurse manager’s role on the hospital unit. There were five themes that emerged in the category of RNs perceived disconnect between work issues and the manager’s role. The daily role, manager meeting time, visibility of nurse managers, no longer a nurse, and RN preferences for the nurse manager role. Conclusion: Findings support past research in relation to the perceptions o

Learning Nursing Practice: A Multisite, Multimethod Investigation of Clinical Education

Nurses agree that direct practice with actual patients is vital, but the teaching methodologies and faculty-student relationships that optimize students\u27 learning in clinical settings have not been documented. This study examined students\u27 thinking and their interactions with faculty during clinical experiences at three academic nursing programs. Findings suggest that missed opportunities for learning, inadequate measures for clinical progress and learning, and lack of interprofessional practice are failing to optimize student clinical learning experiences