1. Ann Intern Med. 2013 Mar 5;158(5 Pt 2):404-9.

doi:
10.7326/0003-4819-158-5-201303051-00007.

Nurse-patient ratios as a patient safety strategy: a systematic review.

Shekelle PG(1).

Author information:
(1)RAND Corporation, 1776 Main Street, Santa Monica, CA 90401, USA.
shekelle@rand.org

A small percentage of patients die during hospitalization or shortly thereafter,

and it is widely believed that more or better nursing care could prevent some of
these deaths. The author systematically reviewed the evidence about nurse
staffing ratios and in-hospital death through September 2012. From 550 titles,
87 articles were reviewed and 15 new studies that augmented the 2 existing
reviews were selected. The strongest evidence supporting a causal relationship
between higher nurse staffing levels and decreased inpatient mortality comes
from a longitudinal study in a single hospital that carefully accounted for
nurse staffing and patient comorbid conditions and a meta-analysis that found a
"dose-response relationship" in observational studies of nurse staffing and
death. No studies reported any serious harms associated with an increase in
nurse staffing. Limiting any stronger conclusions is the lack of an evaluation
of an intervention to increase nurse staffing ratios. The formal costs of
increasing the nurse-patient ratio cannot be calculated because there has been
no evaluation of an intentional change in nurse staffing to improve patient
outcomes.

DOI: 10.7326/0003-4819-158-5-201303051-00007
PMID: 23460097 [Indexed for MEDLINE]

2. Clin Perinatol. 2017 Sep;44(3):713-728. doi: 10.1016/j.clp.2017.05.005. Epub

2017 Jul 14.

Alarm Safety and Alarm Fatigue.

Johnson KR(1), Hagadorn JI(1), Sink DW(2).

Author information:
(1)Department of Pediatrics, University of Connecticut School of Medicine, 263
Farmington Avenue, Farmington, CT 06030, USA; Division of Neonatology,
Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT
06106, USA.
(2)Department of Pediatrics, University of Connecticut School of Medicine, 263
Farmington Avenue, Farmington, CT 06030, USA; Division of Neonatology,
Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT
06106, USA. Electronic address: dsink@connecticutchildrens.org.

Clinical alarm systems have received significant attention in recent years

following warnings from hospital accrediting and health care technology
organizations regarding patient harm caused by unsafe practices. Alarm
desensitization or fatigue from frequent, false, or unnecessary alarms, has led
to serious events and even patient deaths. Other concerns include settings
inappropriate to patient population or condition, inadequate staff training, and
improper use or disabling. Research on human factors in alarm response and of
functionality of medical devices will help clinicians develop appropriate
policies, practices, and device settings for clinical alarms in neonatal
intensive care units.
Copyright © 2017 Elsevier Inc. All rights reserved.

DOI: 10.1016/j.clp.2017.05.005
PMID: 28802348 [Indexed for MEDLINE]

3. Clin Geriatr Med. 2019 May;35(2):265-271. doi: 10.1016/j.cger.2019.01.006. Epub

2019 Mar 1.

Redesigning a Fall Prevention Program in Acute Care: Building on Evidence.

Fridman V(1).

Author information:
(1)Hunter-Bellevue School of Nursing, New York, NY, USA. Electronic address:
viktoriya.fridman@hunter.cuny.edu.

Through education, frontline nurse involvement, and redesigning fall prevention

approach, hourly rounding was promoted as a proactive falls prevention strategy
with the goal of decreasing falls and promoting patient safety, health, and
comfort. Nurses in health care organizations increase patient safety and reduce
patient falls in the hospital setting through hourly rounding with a purpose.
Current practices must be redesigned to ensure that acute care fall prevention
initiatives are consistent and transformational.

Copyright © 2019 Elsevier Inc. All rights reserved.

DOI: 10.1016/j.cger.2019.01.006
PMID: 30929887 [Indexed for MEDLINE]

4. J Patient Saf. 2015 Sep;11(3):135-42. doi: 10.1097/PTS.0000000000000058.

The Relationship Between Patient Safety Culture and Patient Outcomes: A

Systematic Review.

DiCuccio MH(1).

Author information:
(1)From the University of Pittsburgh Medical Center Mercy, Pittsburgh,
Pennsylvania.

CONTEXT: In the past 13 years since the Institute of Medicine report, To Err is
Human, was published, considerable attention was placed on the relationship
between patient safety culture and patient outcomes. Research to understand this
relationship has been conducted; however, now, it is important to systematically
review these studies to determine if there are tools, levels of measure and
outcomes that have been shown to result in significant correlations.
OBJECTIVE: The purpose of this review is to evaluate the state of research
connecting patient safety culture and patient outcomes to determine
nurse-sensitive patient outcomes that have been significantly correlated to
culture of safety and commonly used tools to measure culture of safety in the
studies with significant correlations.
DATA SOURCES: Published English only research articles were considered for the
review. Only studies that directly measured patient outcomes in relationship to
patient safety culture in hospitals involving registered nurses as a participant
were included.
RESULTS: Evidence of relationships between patient safety culture and patient
outcomes exist at the hospital and nursing unit level of analysis; however, the
number of studies finding statistically significant correlations particularly
using nurse-sensitive outcomes is limited.
CONCLUSIONS: The findings from this review suggest that there are emerging
trends indicating that the specific patient safety culture measurement tools,
the level of analysis, and selection of outcome measures are important
considerations in study design. More research is needed to determine
interventions that improve patient safety culture and outcomes.

DOI: 10.1097/PTS.0000000000000058
PMID: 24583952 [Indexed for MEDLINE]

5. J Nurs Adm. 2015 Jun;45(6):319-24. doi: 10.1097/NNA.0000000000000207.

Leadership style and patient safety: implications for nurse managers.

Merrill KC(1).

Author information:
(1)Author Affiliation: Assistant Professor, Brigham Young University, Provo,
Utah.

OBJECTIVE: The purpose of this study was to explore the relationship between
nurse manager (NM) leadership style and safety climate.
BACKGROUND: Nursing leaders are needed who will change the environment and
increase patient safety. Hospital NMs are positioned to impact day-to-day
operations. Therefore, it is essential to inform nurse executives regarding the
impact of leadership style on patient safety.
METHODS: A descriptive correlational study was conducted in 41 nursing
departments across 9 hospitals. The hospital unit safety climate survey and
multifactorial leadership questionnaire were completed by 466 staff nurses.
Bivariate and regression analyses were conducted to determine how well
leadership style predicted safety climate.
RESULTS: Transformational leadership style was demonstrated as a positive
contributor to safety climate, whereas laissez-faire leadership style was shown
to negatively contribute to unit socialization and a culture of blame.
CONCLUSIONS: Nursing leaders must concentrate on developing transformational
leadership skills while also diminishing negative leadership styles.

DOI: 10.1097/NNA.0000000000000207
PMID: 26010281 [Indexed for MEDLINE]

6. Creat Nurs. 2018 May 1;24(2):116-123. doi: 10.1891/1078-4535.24.2.116.

SBAR Tool Implementation to Advance Communication, Teamwork, and the Perception

of Patient Safety Culture.

Bonds RL.

Current evidence reveals that surgical patients are more prone to adverse events
when compared to any other population in the acute care setting. In a military
training hospital, handoff communication between surgical intensive care unit
(SICU) nurses, physicians, and anesthesia providers (certified registered nurse
anesthetists and anesthesiologists) about patients being prepared for surgery
was identified as a problem by an initial inquiry of the staff. This article
discusses an evidence-based project (EBP) that utilized a standardized
multidisciplinary Situation, Background, Assessment, Recommendation (SBAR) tool
to improve communication, teamwork, and the perception of a patient safety
culture between the SICU nurses and physicians and the anesthesia providers in
preparation for surgery. The SICU and anesthesia departments received training
on the SBAR tool, followed by a 7-week implementation period. Standardized
handoff communication utilizing the SBAR method increased by 100%, and
documentation of intraoperative antibiotics on the electronic medication
administration record increased by 43%. Postimplementation results from the
Agency for Healthcare Research and Quality Hospital Survey on Patient Safety
Culture surpassed database benchmarks for handoffs and transitions, overall
perception of patient safety culture, and teamwork across units. This project
reinforced current evidence supporting the use of standardized handoff
communication.

DOI: 10.1891/1078-4535.24.2.116
PMID: 29871729 [Indexed for MEDLINE]

7. J Nurs Care Qual. 2019 Jan/Mar;34(1):40-46. doi: 10.1097/NCQ.0000000000000334.

Association of Nurse Engagement and Nurse Staffing on Patient Safety.

Brooks Carthon JM(1), Hatfield L, Plover C, Dierkes A, Davis L, Hedgeland T,

Sanders AM, Visco F, Holland S, Ballinghoff J, Del Guidice M, Aiken LH.

Author information:
(1)Center for Health Outcomes and Policy Research, and School of Nursing,
University of Pennsylvania, Philadelphia (Drs Brooks Carthon, Hatfield and Aiken
and Messrs Dierkes and Plover); Pennsylvania Hospital, Philadelphia (Dr
Hatfield, Mss Sanders and Del Guidice and Mr Visco); and Penn Presbyterian
Medical Center, Philadelphia, Pennsylvania (Dr Holland, Messrs Davis and
Ballinghoff, and Ms Hedgeland).

BACKGROUND: Nurse engagement is a modifiable element of the work environment and

has shown promise as a potential safety intervention.
PURPOSE: Our study examined the relationship between the level of engagement,
staffing, and assessments of patient safety among nurses working in hospital
settings.
METHODS: A secondary analysis of linked cross-sectional data was conducted using
survey data of 26 960 nurses across 599 hospitals in 4 states. Logistic
regression models were used to examine the association between nurse engagement,
staffing, and nurse assessments of patient safety.
RESULTS: Thirty-two percent of nurses gave their hospital a poor or failing
patient safety grade. In 25% of hospitals, nurses fell in the least or only
somewhat engaged categories. A 1-unit increase in engagement lowered the odds of
an unfavorable safety grade by 29% (P < .001). Hospitals where nurses reported
higher levels of engagement were 19% (P < .001) less likely to report that
mistakes were held against them. Nurses in poorly staffed hospitals were 6% more
likely to report that important information about patients "fell through the
cracks" when transferring patients across units (P < .001).
CONCLUSIONS: Interventions to improve nurse engagement and adequate staffing
serve as strategies to improve patient safety.

DOI: 10.1097/NCQ.0000000000000334
PMCID: PMC6263830
PMID: 29889724 [Indexed for MEDLINE]

Conflict of interest statement: The authors declare no conflicts of interest.

8. J Clin Pharm Ther. 2016 Apr;41(2):128-44. doi: 10.1111/jcpt.12364. Epub 2016 Feb

23.

Pharmacy-led medication reconciliation programmes at hospital transitions: a

systematic review and meta-analysis.

Mekonnen AB(1)(2), McLachlan AJ(1)(3), Brien JA(1)(4).

Author information:
(1)Faculty of Pharmacy, University of Sydney, Sydney, NSW, Australia.
(2)School of Pharmacy, University of Gondar, Gondar, Ethiopia.
(3)Centre for Education and Research on Ageing, Concord Hospital, Sydney, NSW,
Australia.
(4)Faculty of Medicine, St Vincent's Hospital Clinical School, University of New
South Wales, Sydney, NSW, Australia.

WHAT IS KNOWN AND OBJECTIVE: Medication reconciliation is recognized as an

important tool for the prevention of medication discrepancies and subsequent
patient harm at care transitions. However, there is inconclusive evidence as to
the impact of medication reconciliation at hospital transitions overall, as well
as pharmacy-led medication reconciliation services. This review sought to
evaluate the impact of pharmacy-led medication reconciliation interventions on
medication discrepancies at hospital transitions and to categorize these
interventions as single transition interventions or multiple transitions
interventions.
METHODS: PubMed, MEDLINE, EMBASE, IPA, CINHAL and PsycINFO databases, inclusive
from inception to December 2014, were searched. Included studies were published
studies in English that compared the effectiveness of pharmacy-led medication
reconciliation interventions to usual care and that aimed to assess medication
discrepancies at hospital transitions. 'Usual care' was defined as any care
where targeted medication reconciliation was not undertaken as an intervention,
or if an intervention was conducted, it was not provided by a
pharmacist/pharmacy technician.
RESULTS AND DISCUSSION: Nineteen studies which involved a total of 15 525 adult
patients were included. Eleven studies were randomized controlled trials.
Overall, pharmacy-led medication reconciliation intervention usually revealed a
trend towards reduction in medication discrepancies, compared with usual care.
Seventeen studies involving 18 medication reconciliation interventions targeting
the various transitions (admission, 9; discharge, 4; and multiple transitions,
5) were included in the meta-analysis. Compared with usual care, single
medication reconciliation interventions at transitions in care (either admission
or discharge) showed a significant reduction of 66% in patients with medication
discrepancies (RR 0·34; 95% CI: 0·23-0·50) in favour of the intervention. There
was no difference between groups for interventions targeting multiple
transitions (RR 0·88; 95% CI: 0·77-1·02). Subgroup analyses confined to RCTs
showed that there were no differences for target of transition (admission vs.
discharge), type of intervention (multifaceted intervention vs. medication
reconciliation) and setting (single centre vs. multicentre), nor pharmacists vs.
pharmacy technicians (non-RCTs only). Importantly, medication discrepancies of
higher clinical impact were more easily identified through pharmacy-led
interventions than with usual care.
WHAT IS NEW AND CONCLUSION: Pharmacy-led medication reconciliation interventions
were found to be an effective strategy to reduce medication discrepancies, and
had a greater impact when conducted at either admission or discharge but were
less effective during multiple transitions in care. Further studies that are
designed to assess the impact of the involvement of pharmacy technicians in
medication reconciliation are also needed.
© 2016 John Wiley & Sons Ltd.

DOI: 10.1111/jcpt.12364
PMID: 26913812 [Indexed for MEDLINE]

9. J Clin Nurs. 2018 May;27(9-10):1941-1949. doi: 10.1111/jocn.14335. Epub 2018 Apr

19.

Barriers to medication error reporting among hospital nurses.

Rutledge DN(1)(2), Retrosi T(1), Ostrowski G(1).

Author information:
(1)St. Joseph Hospital, Orange, CA, USA.
(2)California State University Fullerton, Fullerton, CA, USA.

AIMS AND OBJECTIVES: The study purpose was to report medication error reporting
barriers among hospital nurses, and to determine validity and reliability of an
existing medication error reporting barriers questionnaire.
BACKGROUND: Hospital medication errors typically occur between ordering of a
medication to its receipt by the patient with subsequent staff monitoring. To
decrease medication errors, factors surrounding medication errors must be
understood; this requires reporting by employees. Under-reporting can compromise
patient safety by disabling improvement efforts.
DESIGN: This 2017 descriptive study was part of a larger workforce engagement
study at a faith-based Magnet® -accredited community hospital in California
(United States).
METHODS: Registered nurses (~1,000) were invited to participate in the online
survey via email. Reported here are sample demographics (n = 357) and responses
to the 20-item medication error reporting barriers questionnaire. Using factor
analysis, four factors that accounted for 67.5% of the variance were extracted.
These factors (subscales) were labelled Fear, Cultural Barriers, Lack of
Knowledge/Feedback and Practical/Utility Barriers; each demonstrated excellent
internal consistency.
RESULTS: The medication error reporting barriers questionnaire, originally
developed in long-term care, demonstrated good validity and excellent
reliability among hospital nurses. Substantial proportions of American hospital
nurses (11%-48%) considered specific factors as likely reporting barriers.
Average scores on most barrier items were categorised "somewhat unlikely." The
highest six included two barriers concerning the time-consuming nature of
medication error reporting and four related to nurses' fear of repercussions.
CONCLUSIONS: Hospitals need to determine the presence of perceived barriers
among nurses using questionnaires such as the medication error reporting
barriers and work to encourage better reporting.
RELEVANCE TO CLINICAL PRACTICE: Barriers to medication error reporting make it
less likely that nurses will report medication errors, especially errors where
patient harm is not apparent or where an error might be hidden. Such
under-reporting impedes collection of accurate medication error data and
prevents hospitals from changing harmful practices.

© 2018 John Wiley & Sons Ltd.

DOI: 10.1111/jocn.14335
PMID: 29495119 [Indexed for MEDLINE]

10. BMJ. 2012 Mar 20;344:e1717. doi: 10.1136/bmj.e1717.

Patient safety, satisfaction, and quality of hospital care: cross sectional
surveys of nurses and patients in 12 countries in Europe and the United States.

Aiken LH(1), Sermeus W, Van den Heede K, Sloane DM, Busse R, McKee M, Bruyneel
L, Rafferty AM, Griffiths P, Moreno-Casbas MT, Tishelman C, Scott A, Brzostek T,
Kinnunen J, Schwendimann R, Heinen M, Zikos D, Sjetne IS, Smith HL, Kutney-Lee
A.

Author information:
(1)Center for Health Outcomes and Policy Research, University of Pennsylvania
School of Nursing, Philadelphia, PA 19104, USA. laiken@nursing.upenn.edu

Comment in
Enferm Clin. 2012 May-Jun;22(3):170-2.
J Nurs Manag. 2017 Apr;25(3):163-166.

OBJECTIVE: To determine whether hospitals with a good organisation of care (such

as improved nurse staffing and work environments) can affect patient care and
nurse workforce stability in European countries.
DESIGN: Cross sectional surveys of patients and nurses.
SETTING: Nurses were surveyed in general acute care hospitals (488 in 12
European countries; 617 in the United States); patients were surveyed in 210
European hospitals and 430 US hospitals.
PARTICIPANTS: 33 659 nurses and 11 318 patients in Europe; 27 509 nurses and
more than 120 000 patients in the US.
MAIN OUTCOME MEASURES: Nurse outcomes (hospital staffing, work environments,
burnout, dissatisfaction, intention to leave job in the next year, patient
safety, quality of care), patient outcomes (satisfaction overall and with
nursing care, willingness to recommend hospitals).
RESULTS: The percentage of nurses reporting poor or fair quality of patient care
varied substantially by country (from 11% (Ireland) to 47% (Greece)), as did
rates for nurses who gave their hospital a poor or failing safety grade (4%
(Switzerland) to 18% (Poland)). We found high rates of nurse burnout (10%
(Netherlands) to 78% (Greece)), job dissatisfaction (11% (Netherlands) to 56%
(Greece)), and intention to leave (14% (US) to 49% (Finland, Greece)). Patients'
high ratings of their hospitals also varied considerably (35% (Spain) to 61%
(Finland, Ireland)), as did rates of patients willing to recommend their
hospital (53% (Greece) to 78% (Switzerland)). Improved work environments and
reduced ratios of patients to nurses were associated with increased care quality
and patient satisfaction. In European hospitals, after adjusting for hospital
and nurse characteristics, nurses with better work environments were half as
likely to report poor or fair care quality (adjusted odds ratio 0.56, 95%
confidence interval 0.51 to 0.61) and give their hospitals poor or failing
grades on patient safety (0.50, 0.44 to 0.56). Each additional patient per nurse
increased the odds of nurses reporting poor or fair quality care (1.11, 1.07 to
1.15) and poor or failing safety grades (1.10, 1.05 to 1.16). Patients in
hospitals with better work environments were more likely to rate their hospital
highly (1.16, 1.03 to 1.32) and recommend their hospitals (1.20, 1.05 to 1.37),
whereas those with higher ratios of patients to nurses were less likely to rate
them highly (0.94, 0.91 to 0.97) or recommend them (0.95, 0.91 to 0.98). Results
were similar in the US. Nurses and patients agreed on which hospitals provided
good care and could be recommended.
CONCLUSIONS: Deficits in hospital care quality were common in all countries.
Improvement of hospital work environments might be a relatively low cost
strategy to improve safety and quality in hospital care and to increase patient
satisfaction.

DOI: 10.1136/bmj.e1717
PMCID: PMC3308724
PMID: 22434089 [Indexed for MEDLINE]

Conflict of interest statement: Competing interests: All authors have completed

the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf
(available on request from the corresponding author) and declare: funding from
the European Union’s Seventh Framework Programme and the National Institute of
Nursing Research, National Institutes of Health; no financial relationships with
any organisations that might have an interest in the submitted work in the
previous three years; no other relationships or activities that could appear to
have influenced the submitted work.