Excerpt

Throughout these pages, you will find peer-reviewed discussions and reviews of a wide range of issues and literature regarding patient safety and quality health care. Owing to the complex nature of health care, this book provides some insight into the multiple factors that determine the quality and safety of health care as well as patient, nurse, and systems outcomes. Each of these 51 chapters and 3 leadership vignettes presents an examination of the state of the science behind quality and safety concepts and challenges the reader to not only use evidence to change practices but also to actively engage in developing the evidence base to address critical knowledge gaps. Patient safety and quality care are at the core of health care systems and processes and are inherently dependent upon nurses. To achieve goals in patient safety and quality, and thereby improve health care throughout this nation, nurses must assume the leadership role.

Contents

• Foreword
  Carolyn M. Clancy, Director; Risa Lavizzo-Mourey, President and CEO.
• Preface
  Ronda G. Hughes, Editor.
• Acknowledgments
  Ronda G. Hughes.
• Peer Reviewers
• Contributing Authors
• 1. Defining Patient Safety and Quality Care
  Pamela H. Mitchell.
  • Introduction
  • Quality Care
  • Patient Safety
  • Nursing As the Key to Improving Quality Through Patient Safety
  • Conclusion
  • References
• 2. Nurses at the “Sharp End” of Patient Care
  Ronda G. Hughes.
  • Background
  • The Everydayness of Errors
  • The Importance of High-Performing Organizations
  • High-Reliability Organizations
  • What Is It Going To Take To Improve the Safety and Quality of Health Care?
  • The Challenge of Change
  • Practice Implications
  • Research Implications
  • Conclusion
  • References
• 3. An Overview of To Err is Human: Re-emphasizing the Message of Patient Safety
  Molla Sloane Donaldson.
  • Introduction
  • Moving the Focus From Errors to Safety
  • Basic Concepts in Patient Safety
  • Conclusion
  • References
• 4. The Quality Chasm Series: Implications for Nursing
  Mary K. Wakefield.
  • Introduction and Background
  • The Quality Chasm Series
  • To Err Is Human: Building a Safer Health System
  • Crossing the Quality Chasm
  • Health Professions Education: A Bridge to Quality
  • Quality Through Collaboration: The Future of Rural Health
  • Future Directions
  • Research Implications
  • References
• 5. Understanding Adverse Events: A Human Factors Framework
  Kerm Henriksen; Elizabeth Dayton; Margaret A. Keyes; Pascale Carayon; Ronda Hughes.
  • Introduction
  • Human Factors—What Is It?
  • Understanding Systems
  • Sociotechnical System Models
  • Human Error—A Troublesome Term
  • A Human Factors Framework
  • Conclusion
  • References
• 6. Clinical Reasoning, Decisionmaking, and Action: Thinking Critically and Clinically
  Patricia Benner; Ronda G. Hughes; Molly Sutphen.
  • Background
  • Critical Thinking
  • Applying Practice Evidence
  • Clinical Grasp
  • Conclusion
  • References
• 7. The Evidence for Evidence-Based Practice Implementation
  Marita G. Titler.
  • Background
  • Research Evidence
  • Practice Implications From Translation Science
  • Conclusion
  • Search Strategy
  • References
• 8. Health Services Research: Scope and Significance
  Donald M. Steinwachs; Ronda G. Hughes.
  • Background
  • History of Health Services Research
  • Goals for Health Services and Patient Outcomes
  • Evaluating the Quality of Health Care
  • Methodologies and Data Sources Used in Health Services Research
  • Conclusion
  • References
• 9. Synergistic Opportunity To Connect Quality Improvement and Emergency Preparedness
  Sally Phillips; Ronda Hughes; Lucy A. Savitz.
  • Background
  • Engaging People in Place
  • Evidence-Based Quality and Safety
  • Practice Implications
  • Research Implications
  • Conclusions
  • References
• 10. Fall and Injury Prevention
  Leanne Currie.
  • Background
  • Fall and Fall-Related Injury Reporting
  • Research Evidence
  • Evidence-Based Practice Implications
  • Research Implications
  • Recommendations From Evidence-Based Practice and Research Implications
  • Conclusion
  • Search Strategy
  • References
• 11. Reducing Functional Decline in Hospitalized Elderly
  Ruth M. Kleinpell; Kathy Fletcher; Bonnie M. Jennings.
  • Background
  • Hospitalization and Patient Safety Considerations for the Elderly
  • Research Evidence
  • Evidence-Based Practice Implications
  • Research Implications
  • Conclusion
  • Acknowledgments
  • References
• 12. Pressure Ulcers: A Patient Safety Issue
  Courtney H. Lyder; Elizabeth A. Ayello.
  • Background
  • Incidence, Mortality, and Costs
  • Risk Factors
  • Implementing a Prevention Plan
  • Management of Pressure Ulcers
  • Adjunctive Therapies
  • Evidence-Based Practice Implications
  • Research Implications
  • Conclusion
  • Search Strategy
  • References
• 13. Patient Safety and Quality in Home Health Care
  Carol Hall Ellenbecker; Linda Samia; Margaret J. Cushman; Kristine Alster.
  • Background
  • Delivering Health Care in the Home
  • Medication Management
  • Fall Prevention
  • Unplanned Hospital Admissions
  • Nurse Work Environment
  • Functional Outcomes and Quality of Life
  • Wound and Pressure Ulcer Management
  • Conclusion
  • Search Strategy
  • References
• 14. Supporting Family Caregivers in Providing Care
  Susan C. Reinhard; Barbara Given; Nirvana Huhtala Petlick; Ann Bemis.
  • Background
  • Caregivers as Clients
  • Research Evidence: Interventions for Caregivers as Clients
  • Caregivers as Providers
  • Research Evidence: Interventions for Caregivers as Providers
  • Research Implications
  • Conclusion
  • Search Strategy
  • References
• 15. Pediatric Safety and Quality
  Susan Lacey; Janis B. Smith; Karen Cox.
  • Background
  • Leaders in Pediatric Safety and Quality
  • Nurse Staffing and Pediatric Outcomes
  • Evidence-Based Pediatric Practice
  • Evidence-Based Clinical Practice Guidelines: Exemplars
  • Other Issues for Pediatric Care
  • Conclusions
  • References
• 16. Prevention—Safety and Quality
  Carol Loveland-Cherry.
  • Background
  • Research Evidence
  • Evidence-Based Practice Implications
  • Research Implications
  • Conclusion
  • Search Strategy
  • References
• 17. Improving the Quality of Care Through Pain Assessment and Management
  Nancy Wells; Chris Pasero; Margo McCaffery.
  • Background
  • Scope of the Problem
  • Assessment of Pain
  • Monitoring the Quality of Pain Management
  • Current Guidelines
  • Research Evidence
  • Evidence-Based Practice Implications
  • Research Implications
  • Conclusion
  • Search Strategy
  • References
• 18. Medication Management of the Community-Dwelling Older Adult
  Karen Dorman Marek; Lisa Antle.
  • Background
  • Risk Factors
  • Research Evidence
  • Practice-Implications: Medication Management Practice Guidelines
  • Research Implications
  • Conclusion
  • Search Strategy
  • Acknowledgments
  • References
• 19. Care Models
  Bonnie M. Jennings.
  • Background
  • Research Evidence
  • Evidence-Based Practice Implications
  • Research Implications
  • Conclusion
  • Search Strategy
  • Acknowledgments
  • References
• 20. Leadership
  Bonnie M. Jennings; Joanne Disch; Laura Senn.
  • Background
  • Research Evidence
  • Evidence-Based Practice Implications
  • What We Do Not Know—Research Implications
  • Acknowledgments
  • References
• 20a. [Vignette] Transforming Health Care for Patient Safety: Nurses’ Moral Imperative To Lead
  Diana J. Mason.
  • Background
  • Research Priorities and Barriers
  • The Moral Imperative
  • Conclusion
  • References
• 20b. [Vignette] Who Should Lead the Patient Quality/Safety Journey?
  Joanne Disch.
  • What Are the Barriers to CNEs Taking on This Particular Leadership Journey?
  • Evidence and Collaboration Will Enable This Journey To Be Taken Successfully
  • References
• 20c. [Vignette] Creation of a Patient Safety Culture: A Nurse Executive Leadership Imperative
  Victoria L. Rich.
  • Background
  • A Culture of Systemic Mindfulness
  • Development of the Systemic Mindfulness Model of Proactive Patient Safety
  • Handling a Medical Error
  • Changing and Holding Generative Culture Gains at the Nurse-Patient Transactional Level
  • Research Implications
  • Conclusion
  • References
• 21. Creating a Safe and High-Quality Health Care Environment
  Patricia W. Stone; Ronda Hughes; Maureen Dailey.
  • Background
  • Research Evidence
  • Evidence-Based Practice Implications
  • Research Implications
  • Conclusion
  • Search Strategy
  • References
• 22. Practice Implications of Keeping Patients Safe
  Ann E. K. Page.
  • Background
  • Nurse Working Conditions
  • Practice Implications
  • Recommendations for Promoting Patient Safety in the Work Environments of Nurses
  • Conclusion
  • References
• 23. Patient Acuity
  Bonnie M. Jennings.
  • Background
  • Research Evidence
  • Evidence-Based Practice Implications
  • Research Implications
  • Conclusion
  • Search Strategy
  • Acknowledgments
  • References
• 24. Restructuring and Mergers
  Bonnie M. Jennings.
  • Background
  • Research Evidence
  • Evidence-Based Practice Implications
  • Research Implications
  • Conclusion
  • Search Strategy
  • Acknowledgments
  • References
• 25. Nurse Staffing and Patient Care Quality and Safety
  Sean P. Clarke; Nancy E. Donaldson.
  • Background
  • Identifying Nurse-Sensitive Outcomes
  • A Framework Relating Nurse Staffing to Patient Care Quality and Safety
  • State of Science on the Relationship Between Nurse Staffing and Patient Outcomes
  • Research Evidence
  • Areas Where the Evidence Base Is Currently Limited
  • Evidence-Based Practice Implications
  • Research Implications
  • Conclusion
  • Search Strategy
  • References
• 26. Work Stress and Burnout Among Nurses: Role of the Work Environment and Working Conditions
  Bonnie M. Jennings.
  • Background
  • Research Evidence
  • Evidence-Based Practice Implications
  • Research Implications
  • Conclusion
  • Search Strategy
  • Acknowledgments
  • References
• 27. Temporary, Agency, and Other Contingent Workers
  Ann E. K. Page.
  • Background
  • Research Evidence
  • Evidence-Based Practice Implications
  • Research Implications
  • Conclusions
  • Search Strategy
  • References
• 28. The Impact of Facility Design on Patient Safety
  John Reiling; Ronda G. Hughes; Mike R. Murphy.
  • Background
  • Research Evidence
  • Addressing the Problem: A Case Study
  • Practice Implications
  • Research Implications
  • Conclusions
  • Search Strategy
  • References
• 29. Turbulence
  Bonnie M. Jennings.
  • Background
  • Research Evidence
  • Evidence-Based Practice Implications
  • Conclusion
  • Search Strategy
  • Acknowledgments
  • References
• 30. Nursing Workload and Patient Safety—A Human Factors Engineering Perspective
  Pascale Carayon; Ayse P. Gurses.
  • Background
  • Concepts and Models of Nursing Workload
  • Research Evidence
  • Practice and Research Implications
  • Conclusion
  • Acknowledgments
  • References
• 31. Organizational Workflow and Its Impact on Work Quality
  Carol Cain; Saira Haque.
  • Background
  • Research Evidence
  • Practice Implications
  • Research Implications
  • Search Strategy
  • References
• 32. Professional Communication
  Jean Ann Seago.
  • Background
  • Research Evidence
  • Practice Implications
  • Research Implications
  • Conclusion
  • Search Strategy
  • References
  • Appendix
• 33. Professional Communication and Team Collaboration
  Michelle O’Daniel; Alan H. Rosenstein.
  • Background
  • Research Evidence
  • Practice Implications
  • Establishing Culture To Support Communication and Team Collaboration
  • Research Implications
  • Conclusions
  • References
• 34. Handoffs: Implications for Nurses
  Mary Ann Friesen; Susan V. White; Jacqueline F. Byers.
  • Background
  • What Is a Handoff?
  • Evidence-Based Practice Implications—Handoffs for Today’s Health Care Environment
  • Research Implications
  • Acknowledgments
  • References
• 35. Error Reporting and Disclosure
  Zane Robinson Wolf; Ronda G. Hughes.
  • Background
  • Research Evidence
  • Evidence-Based Practice Implications
  • Research Implications
  • Conclusions
  • Search Strategy
  • References
• 36. Wrong-Site Surgery: A Preventable Medical Error
  Deborah F. Mulloy; Ronda G. Hughes.
  • Background
  • Causes and Consequences of Wrong-Site Surgery
  • Universal Protocol for Preventing Wrong-Site Surgery
  • Research Evidence
  • Evidence-Based Practice Implications
  • Research Implications
  • Conclusion
  • Search Strategy
  • References
• 37. Medication Administration Safety
  Ronda G. Hughes; Mary A. Blegen.
  • Background
  • Defining Medication Errors
  • Research Evidence—Medication Administration by Nurses
  • Evidence-Based Practice Implications
  • Research Implications
  • Conclusion
  • Search Strategy
  • References
• 38. Medication Reconciliation
  Jane H. Barnsteiner.
  • Background
  • Medication Reconciliation
  • Research Evidence
  • Evidence-Based Practice Implications
  • Research Implications
  • Conclusion
  • Search Strategy
  • References
• 39. Personal Safety for Nurses
  Alison M. Trinkoff; Jeanne M. Geiger-Brown; Claire C. Caruso; Jane A. Lipscomb; Meg Johantgen; Audrey L. Nelson; Barbara A. Sattler; Victoria L. Selby.
  • Background
  • Research Evidence
  • Nurse Injury and Disease Outcomes
  • Mental Health Effects of Nursing Work
  • Violence
  • Research Implications
  • Conclusion
  • Search Strategy
  • References
• 40. The Effects of Fatigue and Sleepiness on Nurse Performance and Patient Safety
  Ann E. Rogers.
  • Background
  • Insufficient Sleep
  • Fatigue Countermeasures and Other Recommended Safety Practices
  • Research Evidence
  • Evidence-Based Practice Implications
  • Research Implications
  • Conclusion
  • Key Terms and Definitions
  • Search Strategy
  • References
• 41. Preventing Health Care–Associated Infections
  Amy S. Collins.
  • Background
  • Definitions of Health Care-Associated Infections
  • Patient Risk Factors for Health Care–Associated Infections
  • Responsibility for Risk Reduction
  • Prevention Strategies
  • Research Implications
  • Conclusions
  • Appendix 1. Resources
  • Appendix 2. Campaign To Prevent Antimicrobial Resistance in Health Care Settings
  • References
• 42. Targeting Health Care–Associated Infections: Evidence-Based Strategies
  Ruth M. Kleinpell; Cindy L. Munro; Karen K. Giuliano.
  • Background
  • Hospital-Associated Pneumonia
  • Urinary Tract Infections
  • Sepsis
  • Antibiotic-Resistant Infections
  • Evidence-Based Practice Implications
  • Research Implications
  • Conclusion
  • References
• 43. Advanced Practice Registered Nurses: The Impact on Patient Safety and Quality
  Eileen T. O’Grady.
  • Background
  • Research Evidence
  • Practice Implications
  • Research Implications
  • Conclusion
  • Search Strategy
  • References
• 44. Tools and Strategies for Quality Improvement and Patient Safety
  Ronda G. Hughes.
  • Background
  • Measures and Benchmarks
  • Quality Improvement Strategies
  • Research Evidence
  • Evidence-Based Practice Implications
  • Research Implications
  • Conclusions
  • Search Strategy
  • References
• 45. AHRQ Quality Indicators
  Marybeth Farquhar.
  • What Are the AHRQ Quality Indicators?
  • Origins and History
  • Development of the AHRQ Quality Indicators
  • What We Know About the AHRQ Quality Indicators
  • The AHRQ QI Modules
  • Current Uses of the AHRQ Quality Indicators
  • What Nurses Need To Know
  • Enhancing the AHRQ Quality Indicators
  • Conclusion
  • Acknowledgments
  • References
• 46. Magnet Environments for Professional Nursing Practice
  Vicki A. Lundmark.
  • Background
  • Reviewing the Evidence
  • Research Evidence
  • Evidence-Based Practice Implications
  • Research Implications
  • Conclusion
  • Search Strategy
  • References
• 47. Patient Safety and Health Information Technology: Role of the Electronic Health Record
  Nancy Staggers; Charlene Weir; Shobha Phansalkar.
  • Background
  • Orders Management in EHRs
  • Barcode Medication Administration in EHRs
  • Decision-Support Systems for Nursing
  • Conclusion
  • Search Strategies
  • Acknowledgments
  • References
• 48. Patient Safety, Telenursing, and Telehealth
  Loretta Schlachta-Fairchild; Victoria Elfrink; Andrea Deickman.
  • Background
  • Research Evidence
  • Evidence-Based Practice Implications
  • Research Implications
  • Conclusion
  • Search Strategy
  • References
• 49. Documentation and the Nurse Care Planning Process
  Gail M. Keenan; Elizabeth Yakel; Dana Tschannen; Mary Mandeville.
  • Background
  • Research Evidence
  • Practice Implications
  • Research Implications
  • Conclusion
  • Search Strategy
  • Acknowledgments
  • References
• 50. Patient Care Technology and Safety
  Gail Powell-Cope; Audrey L. Nelson; Emily S. Patterson.
  • Background
  • Conceptual Framework
  • Practice Implications
  • Research Implications
  • Conclusions
  • References
• 51. Enhancing Patient Safety in Nursing Education Through Patient Simulation
  Carol Fowler Durham; Kathryn R. Alden.
  • Background
  • Types of Simulation
  • Promoting Safety Through Education With the Patient Simulator
  • Use of Patient Simulation in Nursing Education Programs
  • Evidence Supporting the Use of Patient Simulation in Nursing Education
  • Advantages of Patient Simulation in Nursing Education
  • Role of the Educator in Patient Simulation
  • Developing and Using Patient Simulation Scenarios
  • Presimulation
  • Intrasimulation
  • Postsimulation
  • Student Evaluations of HPS Scenarios
  • Practice Implications—The Future of Patient Simulation in Nursing Education
  • Research Implications
  • Conclusion
  • Acknowledgments
  • Appendix A: Simulation Case Presentation
  • References

Suggested citation:

Hughes RG (ed.). Patient safety and quality: An evidence-based handbook for nurses. (Prepared with support from the Robert Wood Johnson Foundation). AHRQ Publication No. 08-0043. Rockville, MD: Agency for Healthcare Research and Quality; March 2008.

Disclaimer: The authors of the papers published in this document are responsible for the content of each paper. Statements in the papers should not be construed as endorsements by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.