Note: Page numbers of article titles are in boldface type. A Advocacy, for patient-centered care, 230 for safe nurse-patient assignments, 267 B Barcode systems, for blood products, 186 187 for patient identification, 184 185 b-blockade and reduction of perioperative cardiac events, 209 215 Blood transfusion, errors in, cognitive, 180 lapse, 180 182, 184 Blood transfusion safety, ABO-incompatibile blood administration and, hemolytic transfusion reaction from, 180 181 ABO-incompatible blood administration and, analysis of systems and human factors in, 182 case example of, 181 182 CauseMapping in case example, 182 183 from patient identification error, 184 barcode systems for positive patient ID, 184 185 hospital initiatives for, 185 182 armband barcode management, 186 187 CareFusion transfusion verification, 187 188 education module for, 185 186 specimen collection verification, 187 staff engagement in, 187 188 standardized barcode labeling for blood products, 186 187 wireless electronic transfusion verification, 185 187 lapse errors in administration, interruptions, 182, 184 patient identification, 181 pretransfusion verification of blood-patient match, 184 process, 180 process analysis for, 180 radiofrequency identification, 185 through technology and process analysis, 179 190 C CareFusion transfusion verification (TV), adoption of, and compliance with, 188 staff engagement at onset, 187 188 training for, 188 Cause-and-effect diagram(s), CauseMapping, 244, 246 248 Ishikawa diagram, 245 246 Cause-and-effect mapping, of critical events, 243 251 Crit Care Nurs Clin N Am 22 (2010) 283 289 doi:10.1016/s0899-5885(10)00041-9 ccnursing.theclinics.com 0899-5885/10/$ see front matter ª 2010 Elsevier Inc. All rights reserved.
284 CauseMapping, in ABO-incompatible blood transfusion case, 182 183 CauseMapping process, analysis in, simple map in, 246 247 split cause in, 247 example in infant heparin overdose, 248 249 problem definition in, 246 problem-solving in, solutions in, 247 249 Causes, categories of, 249 Communication, in coordination of care and for quality outcomes, 259 in interdisciplinary collaborative planning and monitoring, 221 in patient-centered care, 230 interdisciplinary, in off-site perinatal care, 220 221 Confusion Assessment Method for the ICU, assessment of delirium, 165 167 Critical events, analysis of, as process, 244 as tool, 244 245 basic parts in, 245 Ishikawa diagram, cause-and-effect, 245 246 process maps in, 245 root cause analysis of, 245 246 cause-and-effect mapping of, 243 251 error analysis in, barriers to, 244 systems thinking and, at microsystem process level, 244 D Dexmedetonmidine, adverse effects of, 174 for mechanically ventilated patients, 174 E Emergency department (ED), building team relationships to improve safety, 253 260 Enteral nutrition, areas of concern and recommendations, formula contamination, 201 202 labeling, 199, 201 medication administration through feeding tube, 202 203 misconnections in, 201 ordering, 199 200 tube placement, 199, 202 aspiration pneumonia and, prevention of, 204 diarrhea and, assessment of, 204 guidelines for, 198 indications and use of, for adult patients, 198 in pediatric ICU, 198 monitoring for GI function and tolerance, 203 practice recommendations for, 197 198 safe practices for, 197 208 safety campaign, A.L.E.R.T. in, 204 205, 207 A.W.A.R.E. and, 206 207 Errors. See also Medication errors; Medication safety. from human factors, 279 280 from negligence and misconduct, 279 impact of, 279 in blood transfusion, 180 182, 184
285 in hospital staff nursing practice, 280 in patient identification, for blood ptransfusion, 181, 184 185 in planning and plan execution, 218 patient factors in, 281 patient harm from, 281 registered nurses, factors associated with, 279 282 staffing-related, 281 system factors in, 280 281 wrong drug, 222 223 H Hemolytic transfusion reaction (HTR), morbidity and mortality from, 180 181 symptoms and laboratory findings in, 181 Human factors, in errors, 279 280 in incompatible blood transfusion, 182 183 in team work, 254 Human factors analysis, of medical devices, design and use of, 236 238 training for use of, 240 241 I Intensive Care Delirium Screening Checklist, 167 168 Intensive care unit delirium, 161 178 age and, 162 163 assessment of, barriers to implementation of, 175 assessment tools for, 161, 165 167 Confusion Assessment Method for the ICU, 165 167 Intensive Care Delirium Screening Checklist for, 167 168 study of agreement between, 167 barriers between patient and pratitioner in, 167 168, 175 champion representative for prevention and treatment programs, 174 175 dexmedetomidine impact on, 164 environmental modification for, 169 environmental risks for, 163 164 ICU care and, 169 incidence of, 161 163 morbidity and mortality from, 164 165 risk factors for, 163 164 sedative agents and, 164 subtypes of, 161 162 treatment of, atypical antipsychotics for, 171 haloperidol vs., 172 174 dexmedetomidine for, 174 haloperidol for, 169 171 nonpharmacologic, 167 169, 175 pharmacologic, 169 174 Interdisciplinary healthcare teams, building of, for patient care quality and safety, 253 254 conceptual model of, influences on collaboration in, 273 274 interpersonal processses in, 273 274 increasing effectiveness of, 271 278
286 Interdisciplinary (continued) research studies of, attitudes of team members on, 273 cross-functional psychiatric treatment, 271 272 interdisciplinary vs. traditional rounds, 273 limitations of, 271 272 rehabilitation teams and outcomes for stroke patients, 272 relationship between group functioning and outcome, 272 relationship between group functioning and standardized mortality ratio, 272 team development training effect on, 272 273 study of mean LOS on acute care medicine unit, alternative outcome variables and, 276 277 definitions in, 274 design of, 274 for intervention and reversal months, 275 276 insights for future research, 277 278 interdisciplinary rounding in, preexisting, 277 team development training in, 274 275 vs. standardized mortality ratio, 277 Interdisciplinary teams, relationships in, to improve safety on NICU and ED, 253 260 L Labeling, for error reduction, 196 risk for error and, 222 223 M Magnesium sulfate, risks in perinatal patients, 223 224 Medical devices, challenges of, 233 design analyses of, device-specific, 238 239 design flaws and safety improvement for, device combinations with alarms, 235 236 infusion pumps, 234 235, 239 safety-enginered syringes, 234, 238 239 steps in, 240 241 tubing connections, 234, 238 human factors analysis and, for equipment selection, 240 for existing equipment, 240 for training and work design, 240 241 human factors and, in design and use error, 236 238 realistic vs. ideal use in, 239 training in, 239 240 human factors in use of, 233 241 use errors with, common and common contributing factors, 237 design approaches to, 237 238 hierarchy of addressing, 238 Medication errors. See also Errors; Medication safety. ER case studies and safety solutions, 191 196 improper dose/quantity, 193 194 in administration phase, 192 194 in ER setting, 191 196, 192 195 case studies of, 192 194
287 reducton of, 195 196 systems approach to, 191 192 medication use process, 192 reduction recommendations for, automated dispensing devices, 195 196 labeling and, 196 patient ID and, 195 pharmacists in ED, 195 verbal orders and, 195 with high-alert medications, 195 risk with drug nomenclature, labeling, and packaging, 222 223 wrong drug for condition, 194 wrong product, 192 Medication safety. See also Errors; Medication errors. for off-service perinatal patient, 221 224 drug information accessibility for, 222 high-alert drugs and, 222 IV medication risks, 223 224 risk reduction measures for, 222 system-level risk prevention, 222 223 wrong drug error risks, 222 223 nurses and 5 R s for, 221 222 Morbidity, correlation with ICU delirium, 164 165 perioperative b-blockade and, 212 Mortality, from medication errors, 191 ICU delirium risk for, 164 165 perioperative b-blockade and, 212 transfusion-related, 179, 180 181 N Neonatal intensive care unit (NICU), building team relationships to improve safety, 253 260 Nurse/patient ratios, for staffing, 262, 267 Nurses descriptions of working together, implications of, need for clear roles and responsibilities, 258 opportunities to learn strategies for, 258 organizational support, 258 training for, 258 in ED and NICU, 254 259 study of, data analysis in, 255 256 design, setting, participants, data collection in, 254 255 theme results of study, concurrence among members, 257 development and maintenance of relationships, 256 257 personal and professional attributes, 256 vs. teamwork, 255 P Patient-centered care, 227 232 consumers questions about care, 230 231 core concepts of, 229 description of, 228
288 Patient-centered (continued) framework for redesign of health care, 228 partnership between consumers and providers in, 230 231 patient advocacy groups, 230 patient needs in, 229 230 recommendations for, 229 rules in health care reform and, 228 shift from caregiver to patient control, 228 229 Patient identification, barcode systems for, 184 185 error in, ABO-incompatible blood administration and, 184 lapse errors in administration of transfusion, 181 recommendations for reduction of medication errors, 195 Patient information, for off-service perinatal care, gestational age, 219 laboratory data, pregnancy-specific, 220 pregnancy norms and reportable warning signs by trimester, 220 pregnancy status, 218 219 Patient safety, organizational strategies, comparison of staffing plans, 265 policy initiatives for safe staffing and, 267 Perinatal patients, in critical care setting, safe care of, 217 225 in ER or ICU, errors in plan execution in, 218 planning errors in, 218 IV medication risks and, formal failure modes and effects analysis, 224 isotonic fluid and magnesium sulfate bags, 223 with magnesium sulfate, 223 224 risk reduction in off-service care, communication in, 220 221 fetal surveillance, developmentally appropriate, 221 medication safety in, 221 224 patient information in, 218 220 Perioperative b-blockade, and postoperative cardiac risk reduction, 209 210 disparity in the literature, 213 identification of at-risk patients for, 212 213 mortality rate study of, 212 recommendations, 213 current literature, in high-risk patients, 212 randomized, controlled studies of, 211 212 scientific evidence for, 211 212 guidelines for, Agency for Healthcare Research and Quality report, 211, 213 American College of Cardiology/American Heart Association, 211, 213 Physicians, on interdisciplinary teams, 277 Q Quality care, teamwork for, 253 254 Quality outcomes, communication in coordination of care and, 259 S Short staffing, organizational strategies, alternative staffing models, 265 267 contingency staffing, 264 nurse staffing committees, 264 patient safety and, 261 269
289 policy initiatives for safe staffing, 267 strategies for nurse, clarification of circumstances of assignment, 263 264 competence and acceptance of assignment, 264 identifing situations of concern, 263 threat to patient safety, 262 263 Staffing. See also Short staffing. inadequate and safety, 261 269 Institute of Medicine report on, 262 nurse/patient ratios in, 262, 267 patient safety and, 261 269 skill matching in, 262 T Teams, deep-level composition of, 254 Teamwork, human factors in, 254 W Wireless electronic transfusion verification, for blood transfusion safety, 185 187