Category Archives: Patient Safety

What is the standard for changing the inner cannula and performing stoma care in tracheostomies?

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Bottom line:  Recommendations for tracheostomy management include daily cleaning of inner canula, as well as routine cleaning and daily inspections of the stoma.

Summary: 
Tracheostomy: Stoma Care.  Joanna Briggs Institute.  April 26, 2010.
Recommends routine cleaning and daily inspection for signs of infection in the skin around the stoma.  Evidence based on expert opinion.

AACN Procedure Manual, 6th ed, 2011 .
Recommends monitoring skin around stoma for breakdown.

Tracheostomy:  Management.  Joanna Briggs Institute, October 29, 2010.  
Recommends cleaning inner cannula daily based on guidelines that did not cite studies, but relied on expert opinion.

In-patient handoffs

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Goldsmith D, Boomhower M, Lancaster DR, Antonelli M, Kenyon MA, Benoit A, Chang F, Dykes PC.Development of a nursing handoff tool: a web-based application to enhance patient safety.
AMIA Annu Symp Proc. 2010 Nov 13;2010:256-60. PMID: 21346980

Benham-Hutchins MM, Effken JA.Multi-professional patterns and methods of communication during patient handoffs. Int J Med Inform. 2010 Apr;79(4):252-67. Epub 2010 Jan 15.
PMID: 20079686

Apker J, Mallak LA, Applegate EB 3rd, Gibson SC, Ham JJ, Johnson NA, Street RL Jr.Exploring emergency physician-hospitalist handoff interactions: development of the Handoff Communication Assessment. Ann Emerg Med. 2010 Feb;55(2):161-70. Epub 2009 Nov 27. PMID: 19944486

Benham-Hutchins M, Effken JA.Multi-professional communication during a patient handoff. AMIA Annu Symp Proc. 2008 Nov 6:875.
PMID: 18998774

Andrews C, Millar S.Don’t fumble the handoff. Inpatient providers, specialists, and the primary care physician: a medical care delivery system with benefits and complex risks.
J Med Assoc Ga. 2007;96(3):23-4. No abstract available. PMID: 18203554

Apker J, Mallak LA, Gibson SC.Communicating in the “gray zone”: perceptions about emergency physician hospitalist handoffs and patient safety. Acad Emerg Med. 2007 Oct;14(10):884-94.
PMID: 17898250

From JBI+

Nursing: Clinical Handover

A systematic review of nurses’ inter-shift handoff reports in acute care hospitals

Are there any valid instruments for assessing risk for violence in mental health patients and is use of these instruments associated with fewer incidents of assaults on staff by patients?

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Bottom line:  There is some limited evidence that use of risk assessment tools can predict violent behavior by patients and can be associated with  reduction in aggressive incidents.

A systematic review in JBI+ COnNECT (JBI Library of Systematic Reviews. 2009;7(6):175-223) identified one retrospective study (Kling, 2006) of a tool to assess inpatients for risk of violent behavior.  In PubMed this reference led to other studies, including an RCT (Abderhalden, 2008) and a pilot study (Fluttert 2011)

Kling, R., et al., Use of a violence risk assessment tool in an acute care hospital: effectiveness in identifying violent patients. AAOHN Journal, 2006. 54(11): p. 481-7. (Available in print at Health Sciences Center Library.)
Reviewed charts at 1 acute care hospital for 117 violent patients and 161 randomly selected, nonviolent patients admitted during the same period.  Compared findings of a risk assessment tool in these populations.  Tool had moderate senstivity (71%) and high specificity (94%).  Limitation – only 35% of the non-violent patients and 75% of the violent patients were evaluated using the tool.

Abderhalden C, et al. Structured risk assessment and violence in acute psychiatric wards: randomised controlled trial. Br J Psychiatry. 2008 Jul;193(1):44-50.
Cluster RCT randomized 14 psychiatric units to use of Swiss version of the Brøset Violence Checklist (BVC–CH) or usual care for patients admitted to these units.  RESULTS: Adjusted RR indicate 41% reduction in severe aggressive incidents and a 27% decrease in use of coercive measures.  There was no decrease in severity of aggressive incidents.

Fluttert FA, et al. The development of the Forensic Early Warning Signs of Aggression Inventory: preliminary findings toward a better management of inpatient aggression. Arch Psychiatr Nurs. 2011 Apr;25(2):129-37.
Describes development of a new risk assessment tool.

PubMed search:  “Inpatients/psychology”[mesh] AND “Violence/prevention and control”[mesh] AND assess*

Reviewed 4/18/14  AA

Does double checking by two registered nurses prior to injection of insulin or heparin reduce risk of medication errors?

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Bottom line:  There is little evidence to support or to refute the effectiveness of double-checking by nurses to reduce rates of medication errors.

Wimpenny P and Kirkpatrick P.  Roles and systems for routine medication administration to prevent medication errors in hospital-based, acute care settings: a systematic review.  JBI Library of Systematic Reviews. 2010;8(10):405-446.

Hughes RG and Blegen MA.  Medication administration safety.  In:  Patient Safety and Quality:  An Evidence-Based Handbook for Nurses.  AHRQ.  Updated April 2008.  http://www.ahrq.gov/qual/nurseshdbk/docs/HughesR_MAS.pdf
Start with the Policies, Procedures and Protocols section on p. 20.

O’Connell B et al.  Nurses’ attitudes to single checking medications:  before and after its use.  Inter J Nurs Practice.  2007; 13: 377-82.

Studies of errors reported by nurses that address double-checking:

Jarman et al.  Inter J Nurs Practice. 2002; 8: 330-335.  Survey of nurses reporting errors during period of single-checking and period of double-checking.  No significant difference in error rates between the two periods.

Stratton KM et al.  J Pediatr Nurs.  2004;19(6): 385.  Survey of nurses’ perceptions of factors associated with medication errors.  For 28% of the errors reported, nurses identified failure to double-check as a reason for the error.

Reviewed 4/14/2014 AA

How do you ensure proper placement of the vented nasogastric tube?

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PubMed
Results include a recent systematic review, “Implementation of the evidence review on best practice for confirming the correct placement of nasogastric tube in patients in an acute care hospital,”  that aims to define best practices for ensuring proper placement of tube in acute care hospital setting.
http://www.ncbi.nlm.nih.gov/pubmed?otool=emorylib&term=(”Intubation, Gastrointestinal/methods”[MAJR]) AND (suction OR decompression OR medical errors) AND English[lang] AND systematic[sb]
If you want to look at other literature besides systematic reviews, just removew the systematic[sb] from the PubMed search box.

CINAHL
Used search statement similar to PubMed search above.  Most of the relevant references were older, so that information should be covered in the systematic review noted in the PubMed search.  You can view results here.

Reviewed 4/14/14  AA

What is the evidence for best practices in caring for patients with dementia?

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For an overview of caring for patients with dementia:
Dementia, Care of Patient.  In:  Lippincott’s Nursing Procedures and Skills.
Provides overview with references to the literature for care of the patient with dementia.  Also includes a list of additional references that you may find helpful.

For guidelines
Alzheimer disease and Dememtia with Lewy Bodies.  In:  DynaMed.
Go to the Guidelines and Resources Section in each of these entries to see a list of US guidelines. Also, the Treatment Sections include reviews of evidence for management strategies, such as diet, as well as medical therapy.

Reviewed and updated 4/30/2014 ldt