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Recommendations for Fall Related Injury Prevention: A 1-Year Review of Fall Related Root Cause Analyses in the Veterans Health Administration

Video Author: Soncrant, Christina MPH; Neily, Julia RN, MS, MPH; Bulat, Tatjana MD, CMD; Mills, Peter D. PhD, MS
Published on: 05.26.2020
Associated with: January/March 2020, Volume 35, Issue 1;

Injurious falls continue to challenge health care. Learn about this study that analyzed root cause analysis reports on falls and coded injury type, fall type, location, and root causes. There were 154 reported fall RCAs during the study period. Most (83%, n = 128) falls resulted in major injury: hip fractures (43%, n = 66), other fractures (25%, n = 38), and head injury (16%, n = 24). Most falls were unwitnessed (75%, n = 116). Patients who fell were not wearing hip or head protection. These interventions may help prevent future injurious falls. After you watch this informative video, read the full article.

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The aim of this study was to determine patients' (n=503) and nurses' (n=308) perceptions of the quality of nursing care in surgical clinics and influencing factors. Characteristics of patients such as age, gender, complications, and nursing care scores, and characteristics of the nurses such as being satisfied with the current clinic and work affected perceptions of care quality. Patients' perceptions were lower than those of nurses, and some factors belonging to the patients and nurses negatively influenced the quality of care. Dr. Mert shares her study in this video and the article.
Creator: Becker, Sherry MSN-Ed, RN-BC, CWOCN; Hagle, Mary PhD, RN-BC, FAAN; Amrhein, Andra BSN, RN; Bispo, Jeffrey MSN, RN, CNL; Hopkins, Sarah MSN, RN, CNL; Kogelmann, Mary BSN, RN; Porras, Elizabeth BSN, RN; Smith, Melissa M. BSN, RN
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Two evidence-based practice projects and an innovative model provided best evidence and a framework for the implementation and sustainment of a bedside shift report (BSR) quality improvement project. Facilitators and barriers were identified and addressed during planning. Key elements of BSR were incorporated. Implementation was completed in 4 months for 11 units. After 15 months, there was consistent BSR on 82% of the units and improved patient satisfaction with nurses taking time to listen. This is an excellent example of sustainability of a practice change: watch the video and be sure to read the article.
Creator: Francisco, Mary Ann MSN, APN, AGCNS-BC, CCRN-K; Pierce, Nicole L. PhD, RN; Ely, Elizabeth PhD, RN; Cerasale, Matthew T. MD, MPH; Anderson, Daniela MD; Pavkovich, David MD, FACP, FAAP; Puello, Frances MD; Tummala, Sandeep MD; Tyker, Albina MD; D'Souza, Fel
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Proning intubated ICU patients for the management of acute respiratory distress syndrome is an accepted standard of practice. We examined the nursing climate in 4 units and its impact on implementing a novel self-proning protocol to treat COVID-19 patients outside the ICU. Nurses from 4 nursing units were surveyed about the implementation process on the self-proning protocol. Their perception of unit implementation was assessed via the Implementation Climate Scale. Consistent education on the protocol, belief in the effectiveness of the intervention, and a strong unit-based climate of evidence-based practice contributed to greater implementation of the protocol.
Creator: Gode, Autumn MS, APRN-CNS; Kozub, Elizabeth MS, APRN-CNS, CCNS, CNRN, CCRN; Joerger, Kyla BSN, RN-BC; Lynch, Cassandra BSN, NE-BC, OCN; Roche, Maren BSN, RN; Kirven, Justin MD
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Creator: Graham, Kimberly DNP, APRN, ACNS-BC; Ogbuji, Grace BSN, RN; Williams, Zainab BSN, RN; Crain, Maria BSN, RN, BMTCN; Rolin, Barbara MSN, RN-BC; Juala, Jeremy BSN, RN, CMSRN; Larbi, Ida BSN, RN, OCN; Bernard, Noreen EdD, RN, NEA-BC, FAAN; Oster, Cynthia A. P
Duration: 2:40
On inpatient units, patients experience lack of sleep due to noise and multiple interruptions at night. A pilot intervention to support the initiative, “Don't wake the patient for routine care unless the patient's condition or care specifically requires it,” was implemented on 3 units in 3 hospitals. Nurses implemented the project using a purposeful strategy of sleep masks, earplugs, noise detectors, and bundling care. The experiences across the 3 hospital units were positive for providers, patients, and patients' families.
Creator: Stichler, Jaynelle F. DNSc, RN, NEA-BC, FACHE, FAAN; Pelletier, Luc R. MSN, APRN, PMHCNS-BC, FAAN
Duration: 2:17
Person-centered care has become a widely used philosophical framework and yet has varying definitions and characteristics. Learn about the new Patient Empowerment, Engagement, and Activation Survey that can be used to evaluate patients' perspectives of care quality (empowerment and engagement) and readiness for discharge (activation).
Creator: Allen, Alicia MSN, RN, BC; Frederick, Logan MS, RHIA; Hovey, Susan L. PhD, RN
Duration: 3:18
A community hospital recognized patients with multiple chronic conditions had higher rates of inpatient stays and emergency department visits. Patients with multiple chronic conditions enrolled in a supportive care program. Palliative care nurses were assigned to patients enrolled in the program. There was a significant decrease in hospital utilization and inpatient stays following the implementation of the supportive care program. Learn more about this program and how to implement it in your own setting by watching the video and be sure to read the article.
Creator: Tschannen, Dana PhD, RN; Alexander, Catherine DNP, MPH, RN; Tovar, Elizabeth G. PhD, APRN; Ghosh, Bidisha MS; Zellefrow, Cindy DNP, MSEd, RN, LSN, PHNA-BC, EBP-C; Milner, Kerry A. DNSc, RN
Duration: 4:35
Frontline nurse engagement in quality improvement (QI) improves nurse-sensitive outcomes. The purpose of this study was to develop and psychometrically evaluate the Nursing Quality Improvement in Practice (N-QuIP) tool to measure nurses' competency, engagement, and barriers/facilitators to QI engagement. Item development was guided by an expert panel and literature review. Factor analysis and reliability indices were assessed through 681 surveys completed by nurses at one medical center. Preliminary data suggest that the N-QuIP is a valid and reliable tool for assessing nurse QI competence and engagement. Watch the video and read the article.
Creator: Gonzalez, Yovan DNP, RN, FNP-BC; Kozachik, Sharon L. PhD, RN, FAAN; Finnell, Deborah S. DNS, RN, CARN-AP, FAAN
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Screening, brief intervention, and referral to treatment (SBIRT) for substance use has an impact on morbidity and mortality and on health care cost. In this project, nurses in ambulatory care completed an online self-paced program focusing on alcohol and drug use screening, motivational interviewing, and referral to specialty treatment. Postintervention knowledge scores increased. Facilitator and barrier themes included time, education, resources, receptivity, and interprofessional collaboration. The SBIRT online program was feasible for nurses to complete during work hours and resulted in increased SBIRT-related knowledge.
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Bullying and lateral violence are pervasive in the nursing workforce and have profound consequences for nurses, their patients, and the overall health care organization. An iterative, multimodal QI initiative was crafted on the basis of the evidence and principles of transformational, adult learning. Six units were designed to foster learning specific to bullying and lateral violence and their prevention. Each unit consisted of formal lecture content, practice exercises, and reflection. This initiative is appropriate for adoption by other nursing units.
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Duration: 3:02
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Creator: Soncrant, Christina MPH; Neily, Julia RN, MS, MPH; Bulat, Tatjana MD, CMD; Mills, Peter D. PhD, MS
Duration: 8:08
Injurious falls continue to challenge health care. Learn about this study that analyzed root cause analysis reports on falls and coded injury type, fall type, location, and root causes. There were 154 reported fall RCAs during the study period. Most (83%, n = 128) falls resulted in major injury: hip fractures (43%, n = 66), other fractures (25%, n = 38), and head injury (16%, n = 24). Most falls were unwitnessed (75%, n = 116). Patients who fell were not wearing hip or head protection. These interventions may help prevent future injurious falls. After you watch this informative video, read the full article.
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Duration: 2:45
An advanced practice registered nurse (APRN) led a transitional care clinic for stroke survivors. The goal was to improve transitions from hospital to home. Patients seen in the clinic had a lower 30-day readmission rate (1.5%) compared to non clinic patients (13.4%), p = .003). The 90-day readmission proportion was also higher in nonclinic patients (12.8%) vs those seen in the clinic (4.4%), p = .058. The results suggest the APRN-led clinic may impact hospital readmissions in stroke/transient ischemic attack survivors.
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Duration: 2:14
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Creator: Oh, Jong Hee MS, RN, CNL, CRNI, VA-BC; Shelly, Mark MD; Nersinger, Sharon MS, RN, NEA-BC; Cai, Xueya PhD; Olsan, Tobie PhD, RN, NEA-BC, CNL, FNAP
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A community hospital policy of routinely replacing peripheral intravenous catheters (PIVCs) needed updating to clinically indicated replacement. Guided by Lean principles, a clinical nurse leader led a QI small test of change on a 38-bed medical unit. Nurses managed 469 inpatients, receiving 1033 PIVCs. Routine PIVC replacement declined from 34% to 3% (P < .001). PIVC dwell time ranged from 4 to 20 days and did not increase phlebitis (P = .41) or catheter-related bloodstream infections. Clinically-indicated PIVC replacement reduced unnecessary catheter insertions, maintained patient safety, and improved efficiency. Learn about this project in the video and article.