Falls remain a serious problem in hospitals. In 2012, the NDNQI expanded its falls indicator, with the goals of making the indicator suitable for a wider variety of nursing unit types and introducing additional categories of falls. In our lead article Staggs and colleagues discuss the challenges and decisions involved in expanding the NDNQI falls indicator and argue that schemes for categorizing falls by cause are not beneficial in large scale QI efforts to track and prevent inpatient falls. The authors offer recommendations for more useful measures of fall- related quality of care. Many settings have embarked on processes to improve handoffs, but few studies have been done on long-term sustainability. Collet and colleagues report on their implementation of a standardized transfer protocol from a surgical suite to pediatric ICU and its sustainability. Using rapid process improvement technique, the original mean defect rate per handover decreased from 13.2 to 0 at 1 year and 0.3 at 2 years post implementation. This study stresses the importance of long-term assessment of QI initiatives. Modest use of supplemental nurses is cost efficient, but heavy reliance on them to meet staffing needs is not. This is an important study by Xue et al. to guide decisions about use of agency employed supplemental nurses. Registered nurse “second victims” are nurses who are harmed from their involvement in medical errors. Lewis and colleagues found a relationship between RN involvement in preventable adverse events and 2 domains of burnout. Other papers in this issue describe a transitional care program, the outcomes of nurse and family-centered rounds, the relationship of OR scrub staff expertise and development of surgical site infections, and other QI studies. Make sure you also read our columns: Vogelsmeier et al. report on integrating APRNs into nursing homes and Patty shares a new approach to medical safety in a community hospital.
Marilyn H. Oermann, PhD, RN, ANEF, FAAN