October/December 2017 - Volume 32 - Issue 4

  • Marilyn H. Oermann, PhD, RN, FAAN
  • 1057-3631
  • 1550-5065
  • 4 issues / year
  • 1.224

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Preventing pressure ulcers continues to be a need in health care systems. We have 2 articles in this issue that you will be interested in reading: In one of the papers, authors report on the outcomes of using clinical nurse leaders (CNLs) for evaluating pressure ulcer (PU) reporting. The CNL assessments of these reports resulted in a 21% to 50% decrease in the number of hospital-acquired PUs reported in a 3-month time period. The study documented the important role of the CNL in improving the validity and reliability of PU reporting as well as in preventive care. The other article describes use of a Virtual Breakthrough Series to prevent PUs. The project led to a decreased PU rate, documented effective interventions, and supported use of a virtual model for improvement. Leadership engagement is an important aspect of integrating best practices at the bedside. A catheter-associated urinary tract infection (CAUTI) prevention workgroup implemented leadership rounding in partnership with clinical staff to increase participation in prevention initiatives on inpatient units. There was an associated decrease in urinary catheter utilization and CAUTI rates. Other strategies that worked to prevent CAUTIs were peer-to-peer teaching and competency validation: an article describes these nurse-led strategies, which you can adopt easily on your own units. Medication administration errors are difficult to intercept since they occur at the end of the process. In an important study, Thomas and colleagues describe the interruptions, distractions, and cognitive load experienced by RNs during medication administration and their impact on procedure failures and medication administration errors. The focus of this study was unique as it investigated how known individual and environmental factors interacted and led to errors. Two articles in this issue are on rounding. Bahr et al used the Consolidated Framework for Implementation Research to guide a formative evaluation of a redesigned interprofessional team rounding process. The purpose of the redesigned process was to improve health team communication about hospital discharge. The evaluation identified actionable recommendations for modifying the rounding process. Another paper describes the use of interdisciplinary rapid rounds in an observation unit. Get new ideas for your own settings from these and other articles in this issue.



Marilyn H. Oermann, Editor-in-Chief​



Applying the PDSA Framework to Examine the Use of the Clinical Nurse Leader to Evaluate Pressure Ulcer Reporting

Polancich, Shea; Coiner, Sarah; Barber, Rebekah; More

Journal of Nursing Care Quality. 32(4):293-300, October/December 2017.

Applying the PDSA Framework to Examine Use of the Clinical Nurse Leader to Evaluate Pressure Ulcer Reporting

Preventing Pressure Ulcers in the Veterans Health Administration Using a Virtual Breakthrough Series Collaborative

Zubkoff, Lisa; Neily, Julia; King, Beth; More

Journal of Nursing Care Quality. 32(4):301-308, October/December 2017.

Preventing Pressure Ulcers in the Veterans Health Administration Using a Virtual Breakthrough Series

Impact of Interruptions, Distractions, and Cognitive Load on Procedure Failures and Medication Administration Errors

Thomas, Lily; Donohue-Porter, Patricia; Stein Fishbein, Joanna

Journal of Nursing Care Quality. 32(4):309-317, October/December 2017.

Thomas et al. Impact of Interruptions, Distractions, and Cognitive Load on Procedure Failures and Medication Administration Errors

Incorporation of Leadership Rounds in CAUTI Prevention Efforts

Purvis, Suzanne; Kennedy, Gregory D.; Knobloch, Mary Jo; More

Journal of Nursing Care Quality. 32(4):318-323, October/December 2017.

Incorporation of Leadership Rounds in CAUTI Prevention Efforts at an Academic Medical Center

Interprofessional Health Team Communication About Hospital Discharge: An Implementation Science Evaluation Study

Bahr, Sarah J.; Siclovan, Danielle M.; Opper, Kristi; More

Journal of Nursing Care Quality. 32(4):285-292, October/December 2017.

Interprofessional Health Team Communication about Hospital Discharge: An Implementation Science Evaluation Study

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