Joanne Dochterman

Predictors of Medication Errors Among Elderly Hospitalized Patients

Medication errors are a serious safety concern and most errors are preventable. A retrospective study design was employed to describe medication errors experienced during 10187 hospitalizations of elderly patients admitted to a Midwest teaching hospital between July 1, 1998 and December 31, 2001 and to determine the factors predictive of medication errors. The model considered patient characteristics, clinical conditions, interventions, and nursing unit characteristics. The dependent variable, medication error, was measured using a voluntary incident reporting system. There were 861 medication errors; 96% may have been preventable. Most errors were omissions errors (48.8%) and the source was administration (54%) or transcription errors (38%). Variables associated with a medication error included unique number of medications (polypharmacy), patient gender and race, RN staffing changes, medical and nursing interventions, and specific pharmacological agents. Further validation of this explanatory model and focused interventions may help decrease the incidence of medication errors. (Am J Med Qual 2008; 23:115-127)

Cost of Hospital Care for Older Adults with Heart Failure: Medical, Pharmaceutical, and Nursing Costs

OBJECTIVE To determine the impact of patient characteristics, clinical conditions, hospital unit characteristics, and health care interventions on hospital cost of patients with heart failure. DATA SOURCES/STUDY SETTING Data for this study were part of a larger study that used electronic clinical data repositories from an 843-bed, academic medical center in the Midwest. STUDY DESIGN This retrospective, exploratory study used existing administrative and clinical data from 1,435 hospitalizations of 1,075 patients 60 years of age or older. A cost model was tested using generalized estimating equations (GEE) analysis. DATA COLLECTION/EXTRACTION METHODS Electronic databases used in this study were the medical record abstract, the financial data repository, the pharmacy repository; and the Nursing Information System repository. Data repositories were merged at the patient level into a relational database and housed on an SQL server. PRINCIPAL FINDINGS The model accounted for 88 percent of the variability in hospital costs for heart failure patients 60 years of age and older. The majority of variables that were associated with hospital cost were provider interventions. Each medical procedure increased cost by

Nursing interventions and other factors associated with discharge disposition in older patients after hip fractures.

623, each unique medication increased cost by

The effects of hospitalization on multiple units.

179, and the addition of each nursing intervention increased cost by

Estimated Time and Educational Requirements to Perform NIC Interventions

289. One medication and several nursing interventions were associated with lower cost. Nurse staffing below the average and residing on 2-4 units increased hospital cost. CONCLUSIONS The model and data analysis techniques used here provide an innovative and useful methodology to describe and quantify significant health care processes and their impact on cost per hospitalization. The findings indicate the importance of conducting research using existing clinical data in health care.

Describing Use of Nursing Interventions for Three Groups of Patients

Background: The research on hip fractures has been focused on surgical procedures for hip fracture repair; little is known about the contribution of nursing interventions to outcomes. Objectives: To investigate factors, including nursing interventions, associated with the discharge destination of an older patient population hospitalized for a fractured hip or an elective hip procedure. Nursing interventions used during the hospitalized period are identified. Methods: A design model composed of patient characteristics; clinical conditions; nursing unit characteristics; and medical, pharmacy, and nursing interventions related to the outcome of discharge disposition was tested using generalized estimating equations analysis. A total of 116 variables were examined in a sample of 569 hospitalizations from 524 patients aged 60 years and older admitted for treatment of a hip fracture or elective hip procedure in one tertiary care agency over a 4-year period. Data were obtained retrospectively from five clinical databases. Results: Fifty-four percent of the population was discharged to a location other than to home. The predictors of discharge to home were a younger age, admission from home, and having a spouse, as well as receipt of intravenous solutions, diagnostic ultrasound, a lower number of medications, and moderate use of the nursing intervention of bathing. The identification of nursing interventions indicates that those who received routine nursing care for this condition returned home while those who required interventions for complications or prevention of complications were discharged to an institution. Discussion: Using a standardized nursing language with the hospitals information system can provide nurses and others with information that demonstrates the contribution of nursing care to outcomes, including the outcome of discharge to home.

Cost of care for seniors hospitalized for hip fracture and related procedures

Patients are often cared for on multiple units during the course of a hospitalization. This study used general linear modeling and logistic regression analyses to demonstrate the effect of hospitalization on multiple units upon selected nursing treatments, resource use, and clinical outcomes. Primary medical diagnosis, comorbid medical conditions, and severity of illness were controlled for in the analyses. A significant association was found between hospitalizations on multiple units and selected nursing treatments, resource use, and all clinical outcomes except for mortality. Nurses play a central role in coordinating the care that patients receive across inpatient units and are positioned to develop and implement strategies to mediate the negative impacts associated with patients moving across multiple units.

Cost of hospital care for elderly at risk of falling.

PURPOSE To estimate the time to perform and type of personnel to deliver each of the 486 interventions listed and described in the third edition of NIC. METHODS Small groups of research team members rated selected interventions in their area of expertise on education and time needed for each intervention. Education needed was defined as the minimal educational level necessary to perform the intervention in most cases in most states. Rating categories were (a) nursing assistant (NA/LPN/LVN/technician), (b) RN (basic education whether baccalaureate, associate degree, or diploma), or (c) RN with post-basic education or certification. Time needed was defined as the average time needed to perform the intervention. Raters selected one of five possible time estimates: (a) 1 hour. All ratings were reviewed across groups to ensure overall consistency. FINDINGS Results of this exercise provide beginning estimates of the time and education needed for 486 NIC interventions. Twenty percent required 1 hour. More than 70% of the interventions were judged as needing basic RN education to perform. Raters judged RN post-basic education to be required to performi 16% of the interventions, and 14% were deemed appropriate for personnel with NA/LPN education to perform. A monograph, Estimated Time and Educational Requirements to Perform 486 Nursing Interventions, available from http://www.nursing@uiowa.ed/cnc, includes lists of interventions appropriate for each time and education category, as well as time and education ratings according to NIC domains and classes. DISCUSSION The estimates of time and education provided by expert ratings provide a good beginning for cost estimates, resource planning, and reimbursement. The results of this study add to the small but growing body of literature that demonstrates that estimates of time to perform interventions by nurses who are familiar with the interventions is an accurate and efficient method to determine time values. A description of how this information can be used in a costing model is in the July/August 2001 issue of Nursing Economics. CONCLUSIONS NIC has identified the interventions that nurses perform. This study of time to perform and type of personnel to deliver each of the NIC interventions can help nurse leaders make better-informed decisions about cost-effective nursing care.