By Karen Rosenberg
RN SHORTAGES NEGATIVELY IMPACT
PATIENT SAFETY
According to this study:
• • Lower levels of RN staffing in-
crease the risk of death during
a hospital stay.
• • Increasing the number of nurs-
ing assistants cannot compen-
sate for RN shortages.
F aced with a shortage of RNs,
many hospitals rely on nurs-
ing assistants to provide some
­patient care. However, there is
concern about the possible ad-
verse effects of this practice on
patient safety.
In a retrospective, longitudinal,
observational study, researchers
examined how variation in the size
and composition of the nursing
workforce may influence hospital
mortality rates. They assessed staff-
ing levels, which were measured as
hours per patient per day for both
RNs and nursing assistants, and
identified days when admissions
exceeded 125% of the mean for
a given unit, re­flecting a mismatch
between demand and available
staff. The hazard of death in-
creased by 3% for each day a
­patient spent on a unit with RN
staffing below the mean for that
unit. When admissions per RN
exceeded 125% of the mean for
that unit, the hazard of death in-
creased by 5%. The hazard of
death decreased by 3% for every
additional RN hour per patient
during the first five days of a
­patient’s stay. There was no sig-
nificant association between ad-
ditional nursing assistant hours
and hazard of death.
In contrast to the linear associa-
tion between RN staffing and risk
of death, there was evidence that
the risk of death increased when
nursing assistant staffing was ei-
ther above or below the mean.
This may be because additional
nursing assistant staffing creates
ajn@wolterskluwer.com
a division of labor that results in
RNs spending less time with pa-
tients, the authors suggest. They
note that although nursing assis-
tants play an important role in
hospital safety, they shouldn’t be
viewed as substitutes for RNs.
Based on their finding of an in-
creased hazard of death as the
number of new admissions in-
creased, the researchers suggest
that this could be a result of the
increased RN workload associated
with each newly admitted patient.
Consequently, the authors call for
more research into patient turn-
over, in addition to patient census
and acuity, as a workload variable.
The researchers caution that
this study was observational, and
causal inference doesn’t follow di-
rectly from observed associations.
Griffiths P, et al. BMJ Qual Saf 2018 Dec 4
[Epub ahead of print].
COMMUNICATION INTERVENTION
IMPROVES PATIENT SAFETY
According to this study:
• • An intervention designed to im-
prove communication between
health care providers and fam-
ily members may also decrease
harmful medical errors and im-
prove the family’s experience.
T he Joint Commission has
identified communication fail-
ures as a leading cause of the most
harmful medical errors. Research-
ers conducted a multicenter study
of pediatric units to determine
whether implementation of an in-
tervention designed to standard-
ize communication with parents
during hospital rounds would
improve patient safety, the fami-
ly’s experience, and communica-
tion.
Care processes and outcomes
on pediatric units in seven hospitals
were assessed before and after im-
plementation of a family-centered
intervention, which was designed
by a group that included physi-
cians, nurses, and parents. The
intervention consisted of a struc-
tured, high-reliability communica-
tion framework bolstered by health
literacy, family engagement, and
bidirectional communication.
The number of
adverse events
that were due
to error was
significantly lower.
The authors defined a medical
error as a failure in the care pro-
cess (such as administering peni-
cillin to a patient with a penicillin
allergy). They found that the over-
all rate of medical errors didn’t
change significantly after imple-
mentation of the intervention. By
contrast, the number of harmful
medical errors (adverse events that
were due to error and therefore
preventable) was significantly
lower; the rate of nonpreventable
adverse events (those that were
not due to error) also decreased.
There was no change in the rate
of nonharmful errors.
Ratings on six of 25 items re-
lated to the family’s experience im-
proved. Family-centered rounds
occurred more often, and family
and nurse engagement on rounds
improved. Frequency of teaching
on rounds didn’t change after im-
plementation of the intervention.
The authors conclude that the
intervention led to observed im-
provements in patient safety but
acknowledge that the results could
differ in populations that have
lower health literacy than that of
the study population.
Khan A, et al. BMJ 2018;363:k4764. ▼
AJN ▼ March 2019 ▼ Vol. 119, No. 3 51