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NPSF Bibliography
NPSF CURRENT AWARENESS PATIENT SAFETY LITERATURE ALERT
OCTOBER #2, 2004
In an effort to monitor the landscape of patient safety, the NPSF Information Resource Center routinely identifies articles that may be of interest to the patient safety community. This twice-monthly publication is not an exhaustive list of citations, but does pinpoint items of interest from a wide array of publications. Copies of the articles may be obtained through your local medical or public library and the web.
When available, hyperlinks are provided. At means the full-text is available on-line. Through means the item is available for purchase on-line. Also, check Journal Sources for additional information on a given article.
Our thanks and recognition goes to Pat Foy, David Loh, and Linda McGarvey for their contributions to this edition of Current Awareness.
1. Business case for better buildings.
Berry LL, Parker D, Coile RC, Hamilton DK, O'Neill DD, Sadler BL.
Front Health Serv Manag. 2004;21(1):3-24.
Using evidence-based design, the one-time incremental costs of designing and building optimal facilities can be quickly repaid through operational savings and increased revenue - and result in substantial, measurable, and sustainable financial benefits. Discussion topics include stress reduction (patient and staff), safety, and ecological health. The case study is a composite of recently built or redesigned health care facilities. An appendix includes changes and costs and the financial impact of design decisions. An accompanying editorial by Reiling (Facility design focused on patient safety, pg 41-46), notes that investments of additional capital may not create a return necessary to justify the investment, nor is focusing on a healing environment also a focus on patient safety. If building plans are patient safety driven, prioritizing investments to meet safety design principles can still be kept within capital constraints.
Refs: 54 / Code: ADM; ERG
2. Medication transformation: pharmacists on the floor.
Blair R.
Health Manag Technol. 2004;25(10):26,28,30,32-33.
In their system redesign, the Sisters of Mercy Health System no longer considered the pharmacy as a location, but rather as a clinical service - moving it from the basement onto hospital floors and into patient care teams. Discussion includes studies of their existing systems, implementation of bar coding technologies, and that the medication cycle has been reduced 33 percent.
Code: HMI; MED
3. Organisational accidents investigation methodology and lesson learned.
Dien Y, Llory M, Montmayeul R.
J Hazard Mater. 2004;111(1/3):147-153.
Reflecting on accident analysis methods, the article highlights the change from behavioral to organizational approaches by examining two incidents. Organizational properties (network nature, incubation period before a sentinel event, warning signals such as near misses, and whistle blowers speaking up) and factors (weak safety culture, complex/inappropriate organization, limited operational feedback, production pressures, and failure of contols) are discussed. The authors recommend three additional issues be considered in any event analysis: historical reconstruction, development of an organizational network of the event, and inspection of background including the role of managers and decision-making.
Refs: 18 / Code: ERG
4. Facts about the 2005 National Patient Safety Goals.
Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations; 2004.
Available at: http://www.jcaho.org/accredited+organizations/patient+safety/
05+npsg/npsg_facts.htm.
Eleven goals are presented, each with recommendations and a notation as to their program applicability (e.g. to ambulatory care, critical care, long term care, or etc.).
Refs: 41 / Code: INF
5. Catheter-related infections.
Eggimann P, Sax H, Pittet D.
Microb Infect. 2004;6(11):1033-1042.
This paper reviews the epidemiology and impact of catheter-related and catheter-associated infections and of principles of therapy. Prevention methods are presented including guidelines and education.
Code: GEN
6. Effect of workforce issues on patient safety.
Gelinas LS, Loh DY.
Nurs Econ. 2004;22(5):266-272,279.
To build a strong workforce and a culture of high-quality healthcare, focus and resources are needed to strengthen leadership at all levels, assure optimal work design, and implement benchmark and human resource processing. The building blocks for a culture of quality, an organizational model for creating a healthy culture, and performance model measurements are discussed.
Refs: 17 / Code: ADM; ERG; STAF
7. Perils of shift work: evening shift, night shift, and rotating shifts.
Hughes R.
Am J Nurs. 2004;104(9):60-63.
Discussion covers the physical and psychological effects and dangers of shift work and provides recommendations in several areas: including fighting fatigue, establishing support networks and controlling the environment and personal activities.
Refs: 29 / Code: STAF
8. ED overcrowding: meeting many needs.
Isaacman DJ, Poirier MD, King RB, Shaw K, Adams JG.
Pediatr Emerg Care. 2004;20(10):710-716.
Three directors share their methodologies by answering two questions concerning adding staff and use of back-ups. King focuses on solutions to bottlenecks, Shaw notes the importance of data and benchmarking to determine shifts and staffing, and Adams identifies issues needed in a presentation to a CEO. All discuss the importance of involving the entire healthcare team in finding and implementing solutions to overcrowding.
Refs: 9 / Code: ADM; ERG
9. Doc-u-drama: using drama to teach about patient safety.
Kirkegaard M, Fish J.
Fam Med. 2004;36(9):628-630.
Available at: http://www.stfm.org/fmhub/fm2004/October/Margaret628.pdf.
Dramas reveal ordinary ("normal") events that present opportunities for error. Discussion by residents following these 15-minute role-plays may begin with blame finding, but end with a focus on latent error. An example between a float nurse and a resident over a handwritten prescription is given.
Refs: 4 / Code: ADM; EDU; ERG
10. Potentially inappropriate medication prescriptions among elderly nursing home residents: their scope and associated resident and facility characteristics.
Lau DT, Kasper JD, Potter DE, Lyles A.
Health Serv Res. 2004;39(5):1257-1276.
This study found that 50% of residents had at least one potentially inappropriate medication prescription (PIRx) in three months and 3.6% had four or more. Drug-drug interactions, documentation error and redundancy were not considered. Resident factors for higher PIRx include Medicaid coverage, no high school diploma, and nondementia mental disorders. Facility factors include more beds and lower RN-to-resident ratio.
Refs: 39 / Code: GER; MED
11. Clinical practice guidelines for the maintenance of patient physical safety in the intensive care unit: use of restraining therapies.
Maccioli GA, Dorman T, Brown GR, et al.
Crit Care Med. 2003;31(11):2665-2676.
Nine recommendations regarding the use of restraints grew out of this consensus project. Discussion includes ethical considerations, the studies used, and identifying the objectives of restraining therapies.
Refs: 43 / Code: ADM; GER; ICU
12. National voluntary consensus standards for nursing-sensitive care: an initial performance measure set.
Washington, DC: National Quality Forum; 2004.
Available at: http://www.qualityforum.org/txNCFINALpublic.pdf.
Fifteen standards fall into three areas: patient-centered outcome measures (8 - including failure to rescue, falls, restraints, catheter-associated infection, and ventilator-associated pneumonia), nursing-centered intervention measures (3 - concerning smoking cessation counseling), and system-centered measures (4 - including skill mix, nursing care hours per patient day and voluntary turnover). Specifications in the appendix include the source of the measure, the numerator and denominator of each equation, and any exclusions.
Refs: 25 / Code: ADM; GER
13. Measuring patient safety.
Newhouse R, Poe S, eds.
Sudbury, Mass: Jones and Bartlett Publishers; 2005. # 0-7637-2841-1.
Based on a series of presentations at John's Hopkins hospital, this book examines each of the steps necessary to identify, create, develop, implement, and disseminate the results of measurable patient safety projects. Sample forms, available resources, and four case studies focusing on mechanical ventilation, medication reconciliation, chemotherapy safety, and preventing patient aggression respectively are included.
Code: ADM; ERG; REPR
14. Patient-controlled analgesia pumps.
USP Qual Rev. 2004;No. 81:1-3.
Available at: http://www.usp.org/pdf/patientSafety/qr812004-09-01.pdf.
A review of the MEDMARx data found that, when PCAs were involved, the chance for patient harm increases more than 3.5 times. Types of errors and four case studies are presented. Discussion of recommendations to reduce errors covers general, prescribing, dispensing, administering, and monitoring processes.
Code: HMI; MED
15. Preventing medical errors in pediatric emergency medicine.
Selbst SM, Levine S, Mull C, Bradford K, Friedman M.
Pediatr Emerg Care. 2004;20(10):702-709.
The article begins with several illustrative cases of medication error and an epidemiology of medical error. Discussion of the causes of error focus on the pediatric patient, residents, nurses, overcrowding, stress, fatigue, and lack of communication. Recommendations for addressing medical errors are presented.
Refs: 72 / Code: GEN; MED; PED
16. Fatal connection: death caused by direct connection of oxygen tubing into a tracheal tube connector.
Singh S, Leob RG.
Anesth Analg. 2004;99(4):1164-1165.
In this case study, two factors - lack of knowledge by a trainee and that the oxygen extension tube fitted into a tracheal tube connector - resulted in fatal barotrauma. Recommendations for new standards for connectors include adding a flange or ribs.
Refs: 12 / Code: HMI
17. Methicillin-resistant staphylococcus aureus infections in ICU patients.
Sista RR, Oda G, Barr J.
Anesthesiol Clin N Am. 2004;22(3):405-435.
The extensive discussion covers the pathogenesis, epidemiology, treatment, and prevention of MRSA infections. Risk factors, guidelines, and recommendations from the CDC, the Society for Healthcare Epidemiology of America, and other published sources are presented.
Refs: 158 / Code: ICU; INF
18. Partnering with patients to reduce medical errors: guidebook for professionals.
Spath PL, ed.
Chicago, Ill: Health Forum; 2004. # 1-55648-317-7.
Topics covered in this book include safety from the patient's point of view, the patient's role from a provider's perspective, creating opportunities for patient involvement, liability risk, and leadership roles. The book concludes with an example from the Royal Oak Beaumont hospital.
Code: ADM; REL
19. Frequency and preventability of adverse drug reactions in paediatric patients.
Temple ME, Robinson RF, Miller JC, Hayes JR, Nahata MC.
Drug Safety. 2004;27(11):819-829.
This retrospective study found 0.85 ADRs per 100 admissions and that of those, 21% were preventable. The authors conclude implementing strategies to target certain drug classes and increasing ADR awareness by gathering representative data using available resources will help reduce preventable errors.
Refs: 36 / Code: MED; PED
20. Impact of pharmacists' interventions on the pediatric discharge medication process.
Voirol P, Kayser SR, Chang CY, Chang QL, Youmans SL.
Ann Pharmacother. 2004;38(10):1597-1602.
This study found that without pharmacist intervention, 30% of patients were unable to obtain medications within 24 hours of discharge. This was halved when the pharmacist team was involved in the discharge process.
Refs: 14 / Code: MED; PED
21. Advocate Health Care: a systemwide approach to quality and safety.
Willeumier D.
Jt Comm J Qual Safety. 2004;30(10):559-566.
Three challenges are addressed: complexity of the system, underreporting of patient safety events, and medical staff's acceptance of the disclosure policy. Results include a standardized patient safety event form, integrating disparate databases, ongoing education and a 140% increase in reporting, an active patient safety task force, involvement of patients and families as well as medical staff, and decrease in drug administration errors and nosocomial infections. The sentinel event reporting process is included.
Refs: 2 / Code: GEN
22. Surgical wound infection as a performance indicator: agreement of common definitions of wound infection in 4773 patients.
Wilson AP, Gibbons C, Reeves BC, et al.
BMJ. 2004;329(7468):720-723.
This study found small changes made to the CDC definition or its interpretation caused major variations in the percentage of wound infections. Thus, without a standard definition of wound infection using infection rates as a performance indicator is premature and may be misleading.
Refs: 15 / Code: INF
Copyright 2004 National Patient Safety Foundation®
compiled by Holly Burt, MLIS, for the National Patient Safety Foundation®
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