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
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.
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.
Our Nurse of the Week is Paige
Niepoetter, a senior nursing student at Southern Illinois University
Edwardsville (SIUE) who aspires to become a life-changing cancer researcher.
Her drive and academic experiences during her undergraduate years have positioned
her to achieve her dream of becoming a surgical oncologist specializing in
During nursing school, Niepoetter took
advantage of the opportunity to work alongside faculty mentor Chaya Gopalan to
conduct research through the university’s Undergraduate Research and Creative
Activities (URCA) program. Her scholarly work, which studied intermittent
fasting and eating patterns in obese and non-obese rats, has received national
Niepoetter was one of 50 student researchers selected from a pool
of more than 5,000 abstracts to present at the Federation of American Societies
for Experimental Biology DREAM Program’s Experimental Biology 2019 Meeting
She tells advantagenews.com, “Winning the FASEB DREAM travel award was a blessing. Research is a passion of mine, but without proper funding, I wasn’t sure if I’d be able to attend the entire conference. This award made it possible for me to attend various sessions of interest, connect with fellow researchers and gather ideas for new research directions.”
Gopalan also spoke to Niepoetter’s achievements: “Paige is a wonderfully focused student who works hard and is incredibly responsible. She has been in my lab for three years, is on two major research projects, and has been able to secure four abstracts and one manuscript for publication. This is only the beginning, as we will be writing several papers by the end of the summer. Paige will surely do amazing things in her future.”
Niepoetter attributes her success to Gopalan’s mentorship, which
helped her develop her passion for research and clarify her decision to apply
to medical school. The URCA program allowed her to go beyond what she learned
in the classroom and develop her leadership skills and gain a sense of
confidence she wouldn’t have without Gopalan’s mentorship.
To learn more about SIUE senior
nursing student Paige Niepoetter and her aspirations to become a surgical
oncologist specializing in breast cancer, visit here.
From New Years’ Day 2019 through April 11th, the United States has reported 555 cases of measles in 20 states—the second largest measles outbreak reported since the disease was eliminated in 2000. Keep reading to learn the 10 things nurses need to know about the measles outbreak:
1. Measles is brought into the U.S. by travelers who’ve been in foreign countries where the disease is prevalent—countries in Europe, Asia, Africa, and the Pacific. It is then spread in U.S. communities via contact with pockets of unvaccinated populations.
2. Measles outbreaks, defined as three or more reported cases, are currently ongoing in Rockland County New York, New York City, New Jersey, Washington state, Michigan, and the counties of Butte County California. In addition, new cases have recently been identified in New York’s Westchester and Sullivan counties.
3. Once a person is exposed to the measles virus, it may take up to two weeks before symptoms begin to show. A person is contagious four days before the tell-tale rash appears and for four days after. Measles is an airborne virus that can be shed by those infected long before the symptoms arise.
4. There is no available antiviral therapy to cure measles—only supportive therapy for the symptoms, among which are those similar to the common cold: fever, cough, runny nose, sore throat, followed by conjunctivitis and body rash. Measles can sometimes lead to more serious and life-threatening complications such as pneumonia and encephalitis.
5. New York City Mayor Bill de Blasio has declared a health emergency in the neighborhood of Williamsburg, Brooklyn and is mandating unvaccinated residents to become vaccinated. Those not complying could receive violations and fines of $1,000.
6. Mayor de Blasio has sent a team of “disease detectives” into the Hasidic Community in the Williamsburg neighborhood of Brooklyn, where nearly half of the U.S. cases reported are identified.
7. Coincidentally, the New York State Nurses Association just reached an agreement with the NYC Hospital Alliance to hire more nurses to fill vacancies and add new positions.
8. Detroit is urging those Michiganders vaccinated prior to 1989 to receive a booster vaccination.
How Nurses Play a Role
9. The role of nurses in these outbreaks is education and the promotion of vaccination.
10. It is critical that frontline health care professionals are vaccinated themselves in order to prevent the further spread of the virus, particularly when treating those patients infected by the disease.
Four distinct types of anti-vaccination content seen in Facebook posts
Anti-vaccination messages on Facebook could be divided into four distinct themes: trust, alternative, safety, and conspiracy, according to researchers who analyzed comments posted in response to a pediatrics clinic’s pro-vaccination video.
A small sampling of these messages on Facebook found that “anti-vaxxers” had qualitatively different types of arguments that cater to a wide variety of audiences, reported Brian Primack, MD, of the University of Pittsburgh School of Medicine, and colleagues.
However, the one commonality was that all were distrustful of physicians and the medical community, the authors wrote in Vaccine.
The World Health Organization (WHO) lists “vaccine hesitancy” as one of its 10 threats to global health in 2019, and indeed, Primack and colleagues cited the “considerable rise in the rate of nonmedical exemptions from school immunization requirements” in the U.S.
They noted that while prior research has focused on either anti-vaccination content on Twitter, comments in response to celebrity posts, and Facebook groups, the characteristics of individuals posting anti-vaccination content on Facebook has not been thoroughly examined.
“We want to understand vaccine-hesitant parents in order to give clinicians the opportunity to optimally and respectfully communicate with them about the importance of immunization,” Primack said in a statement. “If we dismiss anybody who has an opposing view, we’re giving up an opportunity to understand them and come to a common ground.”
Primack and colleagues examined the profiles of 197 individuals who posted anti-vaccination comments on a Pittsburgh pediatrics practice’s Facebook page in response to a video promoting the vaccine against HPV. These were among “thousands” posted over a period of 8 days considered anti-vaccination, “which we defined as being either (1) threatening (e.g., ‘you’ll burn in hell for killing babies’) and/or (2) extremist (e.g., ‘you have been brainwashed’),” the group explained.
Among the 197 randomly chosen for analysis (“in order to feasibly conduct in-depth quantitative assessment”), they found a large majority of these commenters were women, and almost 80% were parents. About 30% reported an occupation and a little under a quarter reported a post-secondary education. Of the 55 individuals whose political affiliation could be determined, 56% identified as supporters of Donald Trump, while 11% identified as supporters of Bernie Sanders.
There were 116 individuals who had at least one public anti-vaccination post from 2015-2017, with posts about “educational material,” or claims that doctors are uneducated and parents need to educate themselves were the most popular (73%), followed by “media, censorship, and ‘cover up'” or the suggestion that pharmaceutical manufacturers, government, and physicians deliberately fail to disclose adverse vaccine reactions (71%) and “vaccines cause idiopathic illness,” claiming kids who are not vaccinated get less illness (69%).
The four overarching themes were more specifically:
- Trust: emphasizing suspicion about the scientific community, concerns about personal liberty
- Alternatives: focusing on chemicals in vaccines, use of homeopathic remedies over vaccination
- Safety: perceived risks and concerns about vaccination being immoral
- Conspiracy: that government “hides” information that anti-vaccination groups believe to be facts
Co-author Beth Hoffman, BSc, also of the University of Pittsburgh, said that these groups “caution against a blanket approach to public health messages that encourage vaccination.”
“Telling someone in the ‘trust’ subgroup that vaccines don’t cause autism may alienate them because that isn’t their concern to begin with. Instead, it may be more effective to find common ground and deliver tailored messages related to trust and the perception [that] mandatory vaccination threatens their ability to make decisions for their child,” she said in a statement.
Limitations to the data include that these only reflect commenters who responded to a single pro-vaccination video, and do not necessarily reflect “broader discussions of anti-vaccination issues on Facebook.” Demographic data was self-reported, and could not be authenticated, they noted.
The authors disclosed no conflicts of interest.
This story was originally posted on MedPage Today.
An assistant professor at the University of Nevada Las Vegas is doing all that she can to help pregnant women get screened for perinatal depression. Marcia Clevesy, DNP, has been working at a Las Vegas clinic to improve screenings and documentation on a local level, particularly for postpartum depression.
Perinatal depression is the occurrence of a major or minor
depressive episode during pregnancy or up to one year after childbirth, and
affects as many as one in seven mothers. This term also includes postpartum
depression (PPD), a common complication that occurs after childbirth. But routine screenings for these occurrences is
not standard for most health care providers.
Recently, the U.S. Preventive Services Task Force published
a recommendation to provide or refer pregnant women with an increased risk of
perinatal depression to interventions. But while this report has just been released,
Dr. Clevesy has been working to progress research and care for those with PPD,
especially early on in pregnancy.
“It is important for a focus to be placed on detecting perinatal depression early on to prevent complications,” Dr. Clevesy shared with the UNLV News Center. “The earlier we can identify maternal depression the better, because we are then able to get patients into therapy and treatment sooner.”
Opening Up A National Discussion
Dr. Clevesy’s work has major positive impact both locally
and nationally, especially as discussions of mental health overall are becoming
more common and more open throughout the United States. As more people open up
about their mental health in media and online, women are feeling more
comfortable and secure discussing their own concerns and issues with their
healthcare providers, allowing Clevesy and her colleagues to help strengthen
their work in the Las Vegas area.
“I’ve been a women’s health nurse practitioner for many years, and want to continue to elevate the standard of PPD screening beyond simply asking patients if they’re depressed,” Dr. Clevesy told the UNLV News Center. “In collaboration with Dr. Tricia Gatlin, associate dean for undergraduate affairs at the School of Nursing, I recently implemented a system for providers at a local clinic to use an existing, reliable and validated screening tool — the Edinburgh Postnatal Depression Scale (EPDS) — to screen for PPD as a means of promoting best practice among the maternal-child population.”
Dr. Clevesy also shared that since implementing the new
system, PPD screening documentation rates have nearly doubled. Dr. Clevesy’s
work is crucial for enlisting more Las Vegas health care providers to provide depression
screenings for their pregnant patients, whether they use her screening tool or not.
“One tool is not necessarily preferred over the other. What matters is that health care providers are using a validated tool to effectively screen and promote a discussion regarding depression symptoms,” Dr. Clevesy said. “This assessment should start at the beginning of pregnancy and continue into the postpartum period.”