Failure to Rescue–When Nurses Lack Critical Thinking

Failure to Rescue–When Nurses Lack Critical Thinking

Thousands of hospitalized patients die every year and the cause is directly attributed to nurses and their “failure to rescue” the patients within their care. We’ve all heard about that one patient that came in with one issue and died of another. Those of us who have reviewed charts for malpractice cases refer to it as the “snowball effect”—reading the progress notes of a patient who died due to failure to rescue will make you cringe at the glaring errors.

Patients may have one clinical issue, however minor, that if overlooked by the nurse, cascades into a huge mess of concurrent errors and oversights that often leads to the injury or needless death of a patient. Did you ever wonder why this occurs? Short staffing? Maybe. Nurse burnout? Could be. The main contributing factor, though, is that unfortunately there are many nurses who don’t think creatively or innovatively. They don’t act on their assessment findings nor do they follow up on a change in patient condition. They fail to act as advocates for their patient. Nurses who fail to rescue use “traditional thinking” rather than critical thinking.

Failure to rescue always includes four key elements: (1) Omission of care; (2) a failure to recognize a change in patient condition; (3) a failure to communicate a change in patient condition to medical or other staff; and (4) poor or lack of clinical decision making.

Preceptors and nursing instructors, no matter the level of nursing taught (RN, BSN, MSN, NP, or DNP), should review the below list. It contains elements of traditional thinking. Promoting traditional thinking stifles critical thinking.

Nurses who don’t think critically:

  • Don’t learn from their mistakes or the mistakes of other nurses.
  • Demand that nothing changes and have a “but we’ve always done it this way” attitude.
  • Treat each patient interaction in isolation.
  • Fail to “connect the dots” from one interaction to another.
  • Fail to learn about cause and effect.
  • Do not connect new events with prior knowledge.
  • Do not see what is possible in the future.
  • Solve problems in isolation.
  • Demand that all things be done their way and not any other.
  • Allow personal dislikes and prejudices to cloud judgement.
  • Lack self-confidence.
  • Have poor verbal and written communication skills and do not interact well with others.
  • Do not further their education or promote education for others.
  • Force others to make decisions quickly or set time limits on when decisions can be made.

The behavior and clinical actions of nursing preceptors and instructors affect a student or new nurse long after their clinical rotation or orientation has ended. In fact, the actions of a preceptor or instructor will influence the new nurse far into their nursing careers.

The following statements, said by a preceptor or any nurse to another nurse, will stifle critical thinking:

  • “That’s a dumb idea.”
  • “I can’t believe your school didn’t teach you __________.”
  • “Your idea is good, but it won’t work here.”
  • “It’s too complicated so I’ll just do it and you can watch.”
  • “You spend too much time talking with your patients.”
  • “We tried that here on our unit and it didn’t work.”

How do you teach critical thinking to your preceptees and students? Let us know in the comments!

Dip in Avoidable Hospital Deaths

Dip in Avoidable Hospital Deaths

But low-ranking hospitals had nearly double the risk

The estimated number of avoidable deaths in U.S. hospitals each year has dropped, according to updated analysis prepared for The Leapfrog Group by Johns Hopkins University School of Medicine researchers.

Matt Austin, PhD, an assistant professor in the school’s Armstrong Institute for Patient Safety and Quality, and Jordan Derk, MPH, used the latest data from Leapfrog’s semiannual hospital safety grades to estimate that there are 161,250 such deaths each year, down from the 206,000 deaths they estimated three years prior, according to their report.

Austin and Derk said they used 16 measures from Leapfrog’s 2019 data to identify deaths that could clearly be attributed to a patient safety event or closely related prevention process. The reduction is the result of two main factors, they wrote: One, hospitals have made some improvement on the performance measures included in Leapfrog’s safety grades. And, two, some of the measures “have been re-defined and rebaselined” in the past three years, they wrote.

Furthermore, these data likely represent an undercount, Austin and Derk wrote, noting that other studies have estimated anywhere from 44,000 to 440,000 deaths due to medical errors.

“The measures included in this analysis reflect a subset of all potential harms that patients may encounter in U.S. hospitals, and as such, these results likely reflect an underestimation of the avoidable deaths in U.S. hospitals,” they wrote.

“Also, we have only estimated the deaths from patient safety events and have not captured other morbidities that may be equally important,” they added.

The updated analysis was released to coincide with the latest release of Leapfrog’s controversial scores, which assessed quality data from more than 2,600 hospitals and assigned each an “A” through “F” letter grade.

“The good news is that tens of thousands of lives have been saved because of progress on patient safety. The bad news is that there’s still a lot of needless death and harm in American hospitals,” Leapfrog Group President and CEO Leah Binder said in a statement.

Less than one-third (32%) of hospitals secured an “A” grade. More than a quarter (26%) earned a “B.” The group gave a “C” to another 36%, a “D” to 6%, and an “F” to less than 1% of hospitals.

The analysis from Austin and Derk found that the rate of avoidable deaths per 1,000 admissions was 3.24 at “A” hospitals, 4.37 at “B” hospitals, 6.08 at “C” hospitals, and 6.21 and “D” and “F” hospitals combined. That means patients admitted to a “D” or “F” hospital face nearly double the risk of those admitted to an “A” hospital, the Leapfrog group said.

This story was originally posted on MedPage Today.

Healthcare Still Misses the Mark on Patient Safety

Healthcare Still Misses the Mark on Patient Safety

Years after “To Err is Human” report, studies show marginal improvement

Failure to improve working environments for nurses poses a threat to patient safety, a speaker said at a panel discussion hosted by Health Affairs.

In addition, clinician delays in recognizing emerging complications, and communicating concerns effectively with other medical staff, can increase postsurgical mortality, explained another presenter at the briefing Tuesday, which explored progress in patient safety since the 1999 release of the landmark report “To Err is Human: Building a Safer Health System” by the Institute of Medicine (now the National Academies of Sciences, Engineering, and Medicine).

According to the report, 44,000 to 98,000 deaths each year result from medical errors.

“Everyone agrees we haven’t made as much progress as we’d like to make [with reducing medical errors], and the improvements have been uneven,” said Linda Aiken, PhD, RN, professor and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania in Philadelphia.

In a recent Health Affairs study, Aiken and colleagues assessed safety at 535 hospitals in four large states during two time points between 2005 and 2016, and reported that the results were “disappointing.” Only 21% of the hospitals showed “sizeable improvements” in “work environment scores” while 7% saw their scores worsen, Aiken said.

Another 71% of hospitals “basically remained the same,” she said.

Aiken also reported a similar lack of improvement in patient safety measures at hospitals that showed little improvement in their work environment. In the study, about 30% of nurses graded their own hospitals “unfavorably” on measures of patient safety and infection prevention and about 31% of nurses had high scores on the Maslach Burnout Inventory.

Aiken pointed out that “To Err is Human” specifically identified “transforming the work environment of nurses” as an evidence-based strategy to improve patient safety and highlighted the need for “staffing adequacy,” as well as environments that enable nurses to conduct effective “patient surveillance and timely intervention[s].”

And despite the “blame-free culture” espoused by the 1999 report, which stressed that errors are due to problems with systems not individuals, 50% of the nurses in the study by Aiken’s group reported that they believed their errors would be held against them, she said.

Aiken said the recommendation for how to fix the situation hasn’t changed since it was outlined in the 1999 report — “identify safe nurse staffing and supportive work environments as patient safety interventions.”

In another Health Affairs study, Margaret Smith, MD, of the University of Michigan Medical School in Ann Arbor, and colleagues examined the interpersonal and organizational factors that may increase the chance of “failure to rescue,” or deaths following a major surgical complication.

“We decided to take a slightly different view and look at interpersonal, organizational dynamics and their relationship with rescue,” she explained at the Tuesday panel.

Recent studies have explored targets for interventions that could improve rescue, and focused on resource-heavy solutions, such as increasing ICU staff or improving nurse-patient ratios. While important, these factors only account for a proportion of the variation seen in rescue rates among hospitals, Smith noted.

The typical course of events is an operation, followed by a seminal complication, then a domino effect of other complications, which ultimately end in a patient’s death, she added.

Smith’s group conducted 50 semi-structured interviews at five hospitals across Michigan with a range of providers (surgeons, nurses, respiratory therapists), and asked what they felt were the greatest contributors to effective rescue. The study was done from July to December 2016.

After recording and transcribing each 30-60 minute interview, Smith and colleagues identified five core elements as being part of the “successful rescue” of surgical patients:

  • Teamwork: working well together in moments of crisis
  • Action taking: responding swiftly after identifying a complication
  • Psychological safety: ability of all clinicians to feel comfortable expressing their concerns regardless of where they fit in the clinical hierarchy
  • Recognition of complications
  • Communication

The interviewed clinicians said they generally felt they performed well on the first three measures, but said early recognition of complications and effective communication were areas that needed improvement, Smith stated.

For example, attending surgeons said they did not think complications were spotted early enough. “When we’re talking about early recognition, people have this kind of clinical hunch [that] ‘something’s wrong’… [and] how that’s communicated is often very poor,” Smith said.

The challenge is how to communicate these “hunches” in a way that everyone understands them and ways that trigger actionable steps, she added.

In terms of communication, a senior nurse reported that when more providers cared for a single patient, it was more challenging to pass information along, or have information miscommunicated or misinterpreted.

Smith recommended that hospitals focus upstream of these potential crises by providing all clinicians, regardless of their experience, with the tools to know when a patient is deviating from a normal trajectory.

Her group also stressed the need for more effective language in communicating concerns.

“We need to ‘tool and task’ these providers with the skill-set to work on these multidisciplinary teams to communicate and identify developing complications,” she said.

Smith said her group is developing pilot programs to help clinicians recognize when patients are deviating from a traditional course.

If a patient completes a procedure without a complication, certain daily benchmarks should be expected. These benchmarks would be given to junior nurses and night staff, so that even without years of experience, they can recognize when a patient is not on track, Smith said.

This story was originally posted on MedPage Today.

New Report Shows Nurses Need More Support for Necessary Challenges

New Report Shows Nurses Need More Support for Necessary Challenges

A new report from the Robert Wood Johnson Foundation (RWJF) looks into how nurses in the United States can help boost health and well-being for all Americans, but data shows that those in the field are concerned about being able to do all that they can.

Despite wanting to put their skills to use to help communities as care providers, community educators, and policy advocates, nurses across the US are held back from all they can do by challenges like outdated nursing education, looming staffing shortages, and a steep lack of resources for the healthcare system. These difficulties cast a shadow on the future of nursing in the United States.

“There are many issues affecting the health of our nation—opioids, measles outbreaks, low literacy rates, untreated mental illness, lack of affordable housing, and many others. Conversations with hundreds of nurses made it clear that they are willing to help people face these challenges, but they can’t do it alone,” said Paul Kuehnert, DNP, RN, FAAN, associate vice president at RWJF. “Nurses need support from their employers, other health care professionals, community organizations, and government entities to better address unmet needs.”

The nurses interviewed shared that nursing as a profession must evolve to meet the ever-growing needs of patients, as well as the shifts within the industry that hinder nurses from learning and helping to the best of their abilities. They also provided their points of view regarding how prepared nurses are after their training and education, and what resources are provided to them by their employers. Interviewees also discussed that while patient needs are expanding, there is not enough focus on them in health care settings.

“Nurses are uniquely qualified to address many of the unmet needs of people and communities, and this research shows they have a strong desire to do that,” Kuehnert shared. “Nursing is consistently ranked among the most trusted professions, and nurses have firsthand knowledge of what patients and communities need to be healthier.”

To download the report, visit the RWJF website and click the link that says “Nurse Insights on Unmet Needs of Individuals” under the Additional Resources sidebar.

In-Hospital Delirium: A Problem and a Predictor

In-Hospital Delirium: A Problem and a Predictor

In-hospital patients with delirium are vulnerable during the early posthospitalization period

In-hospital delirium is a predictor of readmission, emergency department visits, and discharge to a location other than home, recent research shows.

The development of delirium in the hospital setting impacts about 12.5% of general medical admissions and as many as 81% of intensive care unit patients. Earlier research has shown delirium among hospitalized patients is predictive of prolonged hospital length stay, lengthened mechanical ventilation, and mortality.

The recent research in the Journal of Hospital Medicine featured data collected from more than 700 delirious patients and nearly 8,000 non-delirious patients. The researchers found delirious patients had increased odds for 30-day readmissions, ED visits, and discharge to postacute care facilities.

These results suggest that patients with delirium are particularly vulnerable in the posthospitalization period and are a key group to focusing on reducing readmission rates and post-discharge healthcare utilization,” the researchers wrote.

Linking in-hospital delirium and readmissions

The Journal of Hospital Medicine research builds on earlier studies about in-hospital delirium, the lead author of the research said. “Prior studies have shown that delirium is associated with functional decline at discharge, so these patients may be particularly vulnerable in the days and weeks following hospital discharge. Our work helps to confirm this as we show that patients who become delirious in the hospital are far more likely to be readmitted within 30 days of discharge, compared with patients who do not develop delirium,” said Sara LaHue, MD, a resident physician in the Department of Neurology, School of Medicine, University of California San Francisco.

The new research indicates that hospital-based interventions should be targeted at delirious patients to reduce readmissions, she said. “Hospital-based interventions that reduce the development of delirium may then reduce the complications of delirium, such as readmission.”

Reducing delirium-associated postacute care service utilization

To avoid hospital readmissions linked to delirium, clinicians should focus on preventing patients from becoming delirious in the hospital.

This may include systems for identifying patients at high risk of becoming delirious, screening for active delirium, and enacting interventions that target the underlying cause in order to reduce the severity or duration of delirium. While such a program can take a bit of work to get off the ground, the benefits for patients, their families, and the hospital system can be significant,” LaHue said.

One team member who is often overlooked is the caregiver at home, she said. “Educating caregivers about delirium risk factors can be very helpful — he or she can bring glasses or hearing aids from home, engage the patient in meaningful conversation to help with orientation, and encourage regulation of sleep-wake cycles. If a patient does become delirious, the caregiver can continue to help with these interventions.”

Caregivers at home are an essential component of postacute care, LaHue said. “We know that delirium is associated with functional decline at discharge, so coordinating safe discharge plans with the caregiver, especially to identify [the] need for resources — physical therapy, occupational therapy, home health, and nursing — can potentially help reduce post-discharge complications.”

Follow-up care is another crucial factor, she said. “Ensuring expedited follow-up with a primary care provider, who can assess for any additional needs, is also important.”

This story was originally posted on MedPage Today.

Massachusetts Nurses Association Trying Again for Patient Limit Legislation

Massachusetts Nurses Association Trying Again for Patient Limit Legislation

The Massachusetts Nurses Association (MNA) is trying a second time to establish patient limits in state legislation. This comes six months after losing a ballot question in the November 2018 state election.

As reported by the Boston Business Journal, the current legislation being reviewed now would hire an independent researcher to study issues affecting nurses, such as staffing, violence, injuries, and quality of life. The data collected by the researcher will then be used by state legislators to determine healthcare staffing needs and acute care patient limits.

“If these studies determine there is a best practice limit on the number of patients a nurse should care for at one time, that should inform future policy discussions,” MNA spokesman Joe Markman told the Boston Business Journal.

The original measure from this past election was defeated largely because of lobbying from the Massachusetts Health & Hospital Association (MHA), who spent $25 million to defeat the ballot. This current bill would be revisiting the same legislation, which raises points for state consideration regarding nurse staffing measures.

“The recent ballot measure raised important issues and challenges that our nurses still face today regarding their ability to give patients the quality care they need and deserve,” Massachusetts state Senator Diana DiZoglio, a sponsor of the current legislation, shared with the Boston Business Journal in an email. “While the policy prescription on the ballot was rejected by the majority of voters, we still need to remain vigilant in identifying best practices to ensure the very best patient care is afforded to all.”

MNA has been working to get nurse-to-patient ratios at all Massachusetts hospitals for several years, including a ballot measure in 2014 that was removed, after Governor Deval Patrick passed a law patient limit law. Markman said this study is necessary to convince voters, after the 2018 election.

“The hospital industry spent … million(s) misleading people about those facts and sometimes outright lying,” Markman told the Boston Business Journal. “For example, they continuously said ED wait times would increase with safe patient limits. That is just wrong and not supported by the evidence. Based on how the industry ran its campaign, it’s clear the public will benefit from additional independent studies.”

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