Elizabeth A. Henneman

Using Clinical Simulation to Teach Patient Safety in an Acute/Critical Care Nursing Course

High-fidelity simulation using lifelike mannequins has been used to teach medical and aviation students, but little is known about using this method to educate nurses. The process and methods authors used to develop, implement, and evaluate high-fidelity simulation experiences in an acute/critical care elective for senior nursing students are described. Authors share their insight, experiences, and lessons learned, along with practical information and a framework, in developing simulations and debriefing.

Effect of a collaborative weaning plan on patient outcome in the critical care setting

ObjectiveThe process of weaning from mechanical ventilation can be complex, requiring collaborative care planning by members of the healthcare team. Improved outcomes have been demonstrated to result from collaborative decision-making processes (e.g., when ventilator teams were utilized). The purpose of this study was to evaluate the effect of a collaborative weaning plan (CWP) on length of time on mechanical ventilation, length of stay in the intensive care unit (ICU), and cost. DesignA new, collaborative weaning plan in the form of a weaning board and flowsheet was introduced into a medical intensive care unit (MICU) setting. A pre- and post-quasi-experimental design using historical controls was used to test the hypotheses. Attempts to control for the effects of history were made by collecting data related to patient, staffing, and organizational variables that could independently effect outcome. SettingMICU in a west coast teaching hospital. PatientsCritically ill patients receiving mechanical ventilation for 3 days or greater. InterventionImplementation of a collaborative weaning plan. MeasurementsOutcomes studied included length of stay in the MICU, length of time patients were mechanically ventilated in the MICU, cost per MICU stay, and the incidence of complications (e.g., reventilation, readmission to the ICU, and mortality rate.) Main ResultsThe CWP decreased length of stay in the MICU by 3.6 days (p = .03) and length of ventilator time by 2.7 days (p = .06). There were no significant differences between groups related to cost or incidence of complications. ConclusionsThese results support the usefulness of collaborative structures (such as weaning boards/flowsheets) in decreasing ICU length of stay.

Error identification and recovery by student nurses using human patient simulation: Opportunity to improve patient safety

This study examined types of errors that occurred or were recovered in a simulated environment by student nurses. Errors occurred in all four rule-based error categories, and all students committed at least one error. The most frequent errors occurred in the verification category. Another common error was related to physician interactions. The least common errors were related to coordinating information with the patient and family. Our finding that 100% of student subjects committed rule-based errors is cause for concern. To decrease errors and improve safe clinical practice, nurse educators must identify effective strategies that students can use to improve patient surveillance.

Peer mentoring for tenure-track faculty

Four tenure-track nursing faculty members at a large, research-intensive university came together to help each other learn the role of faculty scholar and to provide discipline, critique, and collegiality for each other with the goal of building research careers. Peer mentoring is usually construed more as senior faculty mentoring newer faculty. In this model, new faculty members mentor each other based on the knowledge gained in their doctoral programs and through sharing experiences with their own mentors. The value of this strategy includes building relationships among diverse faculty members, creating opportunities for collaboration on research projects, and developing camaraderie among members that might not otherwise develop. One year after implementing this innovative strategy for faculty peer mentoring, group members report success in individual and collective scholarship productivity, more research collaboration, improved mutual expertise, and stronger relationships with each other.

Human patient simulation: teaching students to provide safe care

The use of human patient simulation as a teaching methodology for nursing students has become popular. Using human patient simulation effectively demands paying careful attention to the details of the simulation, debriefing, and evaluation processes. Our experience in designing simulation experiences and evaluating student behaviors confirms the resource-intensive nature of human patient simulation and the need for clear, measurable objectives. When used properly, human patient simulation offers a unique opportunity to teach nursing students important patient safety principles.

Analyzing medical processes

This paper shows how software engineering technologies used to define and analyze complex software systems can also be effective in detecting defects in human-intensive processes used to administer healthcare. The work described here builds upon earlier work demonstrating that healthcare processes can be defined precisely. This paper describes how finite-state verification can be used to help find defects in such processes as well as find errors in the process definitions and property specifications. The paper includes a detailed example, based upon a real-world process for transfusing blood, where the process defects that were found led to improvements in the process.

Emergency Department Medication Lists Are Not Accurate

BACKGROUND Medication errors are a common source of adverse events. Errors in the home medication list may impact care in the Emergency Department (ED), the hospital, and the home. Medication reconciliation, a Joint Commission requirement, begins with an accurate home medication list. OBJECTIVE To evaluate the accuracy of the ED home medication list. METHODS Prospective, observational study of patients aged > 64 years admitted to the hospital. After obtaining informed consent, a home medication list was compiled by research staff after consultation with the patient, their family and, when appropriate, their pharmacy and primary care doctor. This home medication list was not available to ED staff and was not placed in the ED chart. ED records were then reviewed by a physician, blinded to the research-generated home medication list, using a standardized data sheet to record the ED list of medications. The research-generated home medication list was compared to the standard medication list and the number of omissions, duplications, and dosing errors was determined. RESULTS There were 98 patients enrolled in the study; 56% (55/98, 95% confidence interval [CI] 46-66%) of the medication lists for these patients had an omission and 80% (78/98, 95% CI 70-87%) had a dosing or frequency error; 87% of ED medication lists had at least one error (85/98, 95% CI 78-93%). CONCLUSION Our findings now add the ED to the list of other areas within health care with inaccurate medication lists. Strategies are needed that support ED providers in obtaining and communicating accurate and complete medication histories.

Improving Patient-Provider Communication A Call to Action

Patients who are communication impaired are at greater risk of medical error and poorer outcomes. Contributing factors that perpetuate ineffective patient-provider communication include the lack of a systematic method for nursing assessment, evaluation, and monitoring of patient-provider communication needs and interventions; and a lack of standardized training of health care providers. We propose a call to action for nursing administrators to position patient-provider communication as a patient safety-care quality priority within the healthcare organization and incorporate bedside practices that achieve effective patient communication, especially with those most vulnerable to impaired communication. Effective patient-provider communication is an essential component of patient care; and in order for communication to be effective, the information must be complete, accurate, timely, unambiguous, and understood by the patient (1). By formally implementing the assessment of patient communication needs into routine care, nursing administrators will create a sense of accountability among bedside nurses to meet the needs of patients who are communication-vulnerable. A patients right to effective patient-provider communication is supported by accreditation standards (2), regulatory guidelines (3, 4), and patient rights declarations (5, 6). Patients have the right to be informed about the care they receive, make educated decisions about their care, and have the right to be listened to by their providers. However, patient communication needs often go unmet or are addressed inappropriately (7-10). In the case of non-English speaking patients, language access services such as the provision of in-person, telephone, or video interpreters and translated documents are either not available or infrequently used (8-11). Many health care institutions rely on ad hoc interpreters such as family, friends, or administrative and custodial staff to communicate and facilitate patient-provider communication, despite the fact that research has shown that the use of ad hoc interpreters can lead to miscommunication and medical errors (12). For critically-ill or nonspeaking patients, nonverbal behaviors, such as mouthing words, gestures, and head nods, are the principal means of communication; however these methods have been shown to be ineffective, fatiguing and inciting frustration (13-18). Often communication is attempted by simply asking yes/no questions and more appropriate communication interventions are not employed. Limiting the patients communication to yes/no answers restricts the patients responses to predictable messages only or messages that meet the a priori expectation of the patients need as determined by the clinician. The absence of effective patient-provider communication has been cited as a significant factor contributing to adverse outcomes (19, 20). In a 2007 public policy paper focused on health literacy, The Joint Commission recommended that health care organizations “make effective communication an organizational priority to protect the safety of patients” and to “incorporate strategies to address patients communication needs across the continuum of care” (21). Effective patient-provider communication is a vital component of this transformation and must be prioritized to improve patient safety.

Surveillance: A Strategy for Improving Patient Safety in Acute and Critical Care Units

Surveillance is a nursing intervention that has been identified as an important strategy in preventing and identifying medical errors and adverse events. The definition of surveillance proposed by the Nursing Intervention Classification is the purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making. The term surveillance is often used interchangeably with the term monitoring, yet surveillance differs significantly from monitoring both in purpose and scope. Monitoring is a key activity in the surveillance process, but monitoring alone is insufficient for conducting effective surveillance. Much of the attention in the bedside patient safety movement has been focused on efforts to implement processes that ultimately improve the surveillance process. These include checklists, interdisciplinary rounds, clinical information systems, and clinical decision support systems. To identify optimal surveillance patterns and to develop and test technologies that assist critical care nurses in performing effective surveillance, more research is needed, particularly with innovative approaches to describe and evaluate the best surveillance practices of bedside nurses.

Nurse Decision Making in the Prearrest Period

There is a significant body of research demonstrating that many hospitalized patients exhibit signs of clinical deterioration prior to experiencing a cardiopulmonary arrest (CPA).This qualitative study used the critical decision method to describe the cues and factors employed by nurses to identify and interrupt a potentially preventable CPA. The cues that nurses used in identifying a patient at risk for CPA were altered level of consciousness and other selected triggers from the Early Warning Scoring System (EWSS) combined with knowledge of the patient and the contextual features of the decision situation. Nurse characteristics that assisted in interrupting an adverse event included previous experiences in prearrest situations, and the ability to function as part of a team. Organizational characteristics that supported the nurse to interrupt included the availability of nurse-initiated monitoring equipment, experience and flexibility of staff, working with a collaborative team, and access to knowledge resources.