Real-Time Reporting of Small Operational Failures in Nursing Care

Overview

Journal Nurs Res Pract

Publisher Wiley

Date 2016 Nov 30

PMID 27895940

Citations 2

Authors

Kathleen R Stevens

Robert L Ferrer

Affiliations

Soon will be listed here.

Abstract

Addressing microsystem problems from the frontline holds promise for quality enhancement. Frontline providers are urged to apply quality improvement; yet no systematic approach to problem detection has been tested. This study investigated a self-report approach to detecting operational failures encountered during patient care. . Data were collected from 5 medical-surgical units over 4 weeks. Unit staff documented operational failures on a small distinctive Pocket Card. Frequency distributions for the operational failures in each category were calculated for each hospital overall and disaggregated by shift. Rate of operational failures on each unit was also calculated. . A total of 160 nurses participated in this study reporting a total of 2,391 operational failures over 429 shifts. Mean number of problems per shift varied from 4.0 to 8.5 problems with equipment/supply problems being the most commonly reported category. . Operational failures are common on medical-surgical clinical units. It is feasible for unit staff to record these failures in real time. Many types of failures were recognized by frontline staff. This study provides preliminary evidence that the Pocket Card is a feasible approach to detecting operational failures in real time. Continued research on methodologies to investigate the impact of operational failures is warranted.

Citing Articles

Therapist perceptions of a rehabilitation research study in the intensive care unit: a trinational survey assessing barriers and facilitators to implementing the CYCLE pilot randomized clinical trial.

Reid J, McCaskell D, Kho M Pilot Feasibility Stud. 2019; 5:131.

PMID: 31741746 PMC: 6849178. DOI: 10.1186/s40814-019-0509-3.

Operational Failures Detected by Frontline Acute Care Nurses.

Stevens K, Engh E, Tubbs-Cooley H, Conley D, Cupit T, DErrico E Res Nurs Health. 2017; 40(3):197-205.

PMID: 28297072 PMC: 5549458. DOI: 10.1002/nur.21791.

References

James J . A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013; 9(3):122-8. DOI: 10.1097/PTS.0b013e3182948a69. View

Monarch K . The mark of excellence: the ANCC magnet recognition program. S C Nurse (1994). 2002; 9(4):21-2. View

Halbesleben J, Wakefield D, Wakefield B . Work-arounds in health care settings: Literature review and research agenda. Health Care Manage Rev. 2007; 33(1):2-12. DOI: 10.1097/01.HMR.0000304495.95522.ca. View

Martin S, Greenhouse P, Merryman T, Shovel J, Liberi C, Konzier J . Transforming care at the bedside: implementation and spread model for single-hospital and multihospital systems. J Nurs Adm. 2007; 37(10):444-51. DOI: 10.1097/01.NNA.0000285152.79988.f3. View

Needleman J, Pearson M, Upenieks V, Yee T, Wolstein J, Parkerton M . Engaging Frontline Staff in Performance Improvement: The American Organization of Nurse Executives Implementation of Transforming Care at the Bedside Collaborative. Jt Comm J Qual Patient Saf. 2016; 42(2):61-9. DOI: 10.1016/s1553-7250(16)42007-6. View

Tucker A, Singer S, Hayes J, Falwell A . Front-line staff perspectives on opportunities for improving the safety and efficiency of hospital work systems. Health Serv Res. 2008; 43(5 Pt 2):1807-29. PMC: 2654160. DOI: 10.1111/j.1475-6773.2008.00868.x. View

Baskerville N, Liddy C, Hogg W . Systematic review and meta-analysis of practice facilitation within primary care settings. Ann Fam Med. 2012; 10(1):63-74. PMC: 3262473. DOI: 10.1370/afm.1312. View

Tucker A, Spear S . Operational failures and interruptions in hospital nursing. Health Serv Res. 2006; 41(3 Pt 1):643-62. PMC: 1713207. DOI: 10.1111/j.1475-6773.2006.00502.x. View

Grumbach K, Bainbridge E, Bodenheimer T . Facilitating improvement in primary care: the promise of practice coaching. Issue Brief (Commonw Fund). 2012; 15:1-14. View

10.

Rutherford P, Moen R, Taylor J . TCAB: the 'how' and the 'what'. Am J Nurs. 2009; 109(11 Suppl):5-17. DOI: 10.1097/01.NAJ.0000362010.68589.27. View

11.

Needleman J, Parkerton P, Pearson M, Soban L, Upenieks V, Yee T . Overall effect of TCAB on initial participating hospitals. Am J Nurs. 2009; 109(11 Suppl):59-65. DOI: 10.1097/01.NAJ.0000362028.00870.e5. View

12.

Mayfield S . Hospitals in pursuit of excellence. Hosp Health Netw. 2009; 83(2):48. View

13.

Reason J . Human error: models and management. BMJ. 2000; 320(7237):768-70. PMC: 1117770. DOI: 10.1136/bmj.320.7237.768. View

14.

Tucker A, Heisler W, Janisse L . Designed for workarounds: a qualitative study of the causes of operational failures in hospitals. Perm J. 2014; 18(3):33-41. PMC: 4116263. DOI: 10.7812/TPP/13-141. View

15.

Upenieks V, Needleman J, Soban L, Pearson M, Parkerton P, Yee T . The relationship between the volume and type of transforming care at the bedside innovations and changes in nurse vitality. J Nurs Adm. 2008; 38(9):386-94. DOI: 10.1097/01.NNA.0000323959.52415.86. View