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Incident Reports (incident + report)
Terms modified by Incident Reports Selected AbstractsNurse absenteeism and workload: negative effect on restraint use, incident reports and mortalityJOURNAL OF ADVANCED NURSING, Issue 6 2007Lynn Unruh Abstract Title.,Nurse absenteeism and workload: negative effect on restraint use, incident reports and mortality Aim., This paper is a report of a study to assess the impact of nurse absenteeism on the quality of patient care. Background., Nurse absenteeism is a growing management concern. It can contribute to understaffed units, staffing instability, and other factors that could have a negative impact on patient care. The impacts of absenteeism on the quality of nursing care have rarely been studied. Method., Retrospective monthly data from incident reports and staffing records in six inpatient units for 2004 were analysed. Dependent variables were the numbers of restraints, alternatives to restraints, incident reports, deaths, and length of stay. Explanatory variables were nurse absenteeism hours, patient days per nursing staff, and interaction between these variables. Controls were patient acuity and unit characteristics. Fixed effects regressions were analysed as regular or negative binomial models. Findings., Neither high Registered Nurse absenteeism nor high patient load was related to restraint use when taken separately. However, high Registered Nurse absenteeism was related to restraint use when patient load was high. Registered Nurse absenteeism was related to a lower use of alternatives to restraints. Incident reports were increased by high patient load, but not absenteeism, or absenteeism given patient load. When both patient load and absenteeism were high, deaths were higher also. Conclusion., Absenteeism alone may not be a strong factor in lowering quality, but the combination of high Registered Nurse absenteeism and high patient load could be a factor. Staffing and absenteeism may be part of a vicious cycle in which low staffing contributes to unit absenteeism, which contributes to low staffing, and so on. [source] Characteristics of Household Addresses That Repeatedly Contact 911 to Report Intimate Partner ViolenceACADEMIC EMERGENCY MEDICINE, Issue 6 2004Debra Houry MD Abstract Objectives: To determine whether households that generate several 911 calls differ in important ways from those that make a single call and to determine whether households that generate repeat 911 calls for intimate partner violence (IPV) experience more severe violence than those that do not. Methods: All cases of police-documented IPV were reviewed and linked with their respective 911 calls. Each incident report was reviewed to determine the relationship between the offender and victim, demographic characteristics of the offender and victim, weapon and substance involvement, prior incidents of IPV, and violence severity. Results: Of the 1,505 IPV addresses identified during the 12-month study interval, 1,010 (67.1%) placed more than one phone call to report IPV. Sixty-nine percent of African American victims, 50.6% of white victims, and 36.8% of Hispanic victims were repeat callers (p < 0.001). There were no differences between addresses that generated repeat calls versus single calls with respect to offender alcohol or drug involvement, presence of children, victim age, or offender age. Sixty-seven percent of households with severe violence and 66.9% of households with minor violence generated repeat 911 calls (p = 0.98). Conclusions: Ethnic differences in 911 use for IPV exist between African Americans, whites, and Hispanics. However, unknown societal, economic, or cultural issues could have influenced this finding. Households that repeatedly contacted 911 during the study interval to report IPV were not more likely to experience severe violence than those that placed a single 911 call. [source] Examining the characteristics of workplace violence in one non-tertiary hospitalJOURNAL OF CLINICAL NURSING, Issue 3-4 2010Rose Chapman Aim., This study sought to determine the prevalence and characteristics of workplace violence directed at a volunteer sample of nurses at one non-tertiary hospital. Respondents' reasons for not reporting these incidents were also investigated. Background., Incidents of workplace violence are increasing worldwide. However, no studies have investigated this phenomenon from the perspective of nurses in Western Australian non-tertiary hospitals. Design., Survey. Method., A survey was distributed to all 332 nurses working in several areas of one non-tertiary hospital in Western Australia to determine their experiences of workplace violence over a 12 month period. Findings., Of the 113 nurses who agreed to participate in this study, 75% reported experiencing workplace violence in the previous twelve months. When asked about their most recent incident, 50% of the nurses said they had reported it verbally, mostly to more senior staff. Only 16% of the nurses completed an official incident report. Reasons for not reporting included the view that WPV is just part of the job and the perception that management would not be responsive. Conclusion., This study showed that for this sample of nurses violent events are occurring at a rate that is similar to those reported in other studies. This finding should be of great concern to the organisation and the community in general. Relevance to clinical practice., Organisations are obliged to improve the safety of the workplace environment for both staff and patients. The findings of our study may be of help to healthcare institutions in developing education programmes for nurses, patients and their friends and relatives to reduce the impact and frequency of workplace violence. [source] Refined aquatic risk assessment for aldicarb in the United StatesINTEGRATED ENVIRONMENTAL ASSESSMENT AND MANAGEMENT, Issue 1 2010Dwayne RJ Moore Abstract Aldicarb is a systemic insecticide applied directly to soil and to control mites, nematodes, and aphids on a variety of crops (e.g., cotton, potatoes, peanuts). It is highly soluble in water (6,000 mg/L) and mobile in soils (Koc,=,100). As a result, aldicarb has the potential to be transported to aquatic systems close to treated fields. The US Environmental Protection Agency (USEPA) recently conducted an aquatic screening-level ERA for aldicarb as part of the re-registration review process. We conducted a refined risk assessment for aldicarb to characterize better the risks posed by aldicarb to fish and invertebrates inhabiting small freshwater ponds near agricultural areas. For the exposure assessment, tier II PRZM/EXAMS (Predicted Root Zone Model [PRZM] and Exposure Analysis Modelling System [EXAMS]) modelling was conducted to estimate 30-y distributions of peak concentrations of aldicarb and the carbamate metabolites (aldicarb sulfoxide, aldicarb sulfone) in surface waters of a standard pond arising from different uses of aldicarb. The effects assessment was performed using a species sensitivity distribution (SSD) approach. The resulting risk curves as well as available incident reports suggest that risks to freshwater fish and invertebrates from exposure to aldicarb are minor. The available monitoring data did not provide conclusive evidence about risks to aquatic biota. Integr Environ Assess Manag 2010; 6:102,118. © 2009 SETAC [source] Nurse absenteeism and workload: negative effect on restraint use, incident reports and mortalityJOURNAL OF ADVANCED NURSING, Issue 6 2007Lynn Unruh Abstract Title.,Nurse absenteeism and workload: negative effect on restraint use, incident reports and mortality Aim., This paper is a report of a study to assess the impact of nurse absenteeism on the quality of patient care. Background., Nurse absenteeism is a growing management concern. It can contribute to understaffed units, staffing instability, and other factors that could have a negative impact on patient care. The impacts of absenteeism on the quality of nursing care have rarely been studied. Method., Retrospective monthly data from incident reports and staffing records in six inpatient units for 2004 were analysed. Dependent variables were the numbers of restraints, alternatives to restraints, incident reports, deaths, and length of stay. Explanatory variables were nurse absenteeism hours, patient days per nursing staff, and interaction between these variables. Controls were patient acuity and unit characteristics. Fixed effects regressions were analysed as regular or negative binomial models. Findings., Neither high Registered Nurse absenteeism nor high patient load was related to restraint use when taken separately. However, high Registered Nurse absenteeism was related to restraint use when patient load was high. Registered Nurse absenteeism was related to a lower use of alternatives to restraints. Incident reports were increased by high patient load, but not absenteeism, or absenteeism given patient load. When both patient load and absenteeism were high, deaths were higher also. Conclusion., Absenteeism alone may not be a strong factor in lowering quality, but the combination of high Registered Nurse absenteeism and high patient load could be a factor. Staffing and absenteeism may be part of a vicious cycle in which low staffing contributes to unit absenteeism, which contributes to low staffing, and so on. [source] A 3-year study of medication incidents in an acute general hospitalJOURNAL OF CLINICAL PHARMACY & THERAPEUTICS, Issue 2 2008L. Song MPhil Summary Background and objective:, Inappropriate medication use may harm patients. We analysed medication incident reports (MIRs) as part of the feedback loop for quality assurance. Methods:, From all MIRs in a university-affiliated acute general hospital in Hong Kong in the period January 2004,December 2006, we analysed the time, nature, source and severity of medication errors. Results:, There were 1278 MIRs with 36 (range 15,107) MIRs per month on average. The number of MIRs fell from 649 in 2004, to 353 in 2005, and to 276 in 2006. The most common type was wrong strength/dosage (36·5%), followed by wrong drug (16·7%), wrong frequency (7·7%), wrong formulation (7·0%), wrong patient (6·9%) and wrong instruction (3·1%). 60·9%, 53·7% and 84·0% of MIRs arose from handwritten prescription (HP) rather than the computerized medication order entry in 2004, 2005 and 2006 respectively. In 43·1% of MIRs, preregistration house officers were involved. Most errors (80·2%) were detected before any drug was wrongly administered. The medications were administered in 212 cases (19·7%), which resulted in an untoward effect in nine cases (0·8%). Conclusions:, The most common errors were wrong dosage and wrong drug. Many incidents involved preregistration house officers and HPs. Our computerized systems appeared to reduce medication incidents. [source] Predictors of serious injury among hospitalized patients evaluated for falls,,JOURNAL OF HOSPITAL MEDICINE, Issue 2 2010Sara M. Bradley MD Abstract BACKGROUND: Inpatient falls are common and result in significant patient morbidity. OBJECTIVE: To identify predictors of serious injury being found on imaging studies of inpatients evaluated after a fall. DESIGN: Retrospective study. SETTING: An 1171-bed urban academic medical center. PATIENTS: All inpatients who fell on thirteen medical and surgical units from January 1 to December 31, 2006. MEASUREMENTS: Patient characteristics, circumstances surrounding falls, fall-related injuries, and length of stay were collected through review of incident reports and computerized medical records. Primary outcome of fall-related injury was determined by evidence of injury on imaging studies within two weeks of the fall. Univariate and multivariate logistic regression were used to calculate adjusted odds ratios (ORs) for injury after an inpatient fall. RESULTS: A total of 513 patients had 636 falls during the study time period. Fall incidence rate was 1.97 falls per 1,000 patient days. 95 patients (19%) fell multiple times (range, 2-6 events); 74% of the falls occurred in patients who were previously assessed as being "at risk" by the nursing staff. Multivariate analysis, adjusting for age and sex, found evidence of trauma after a fall (OR = 24.6, P < 0.001) and ambulatory status (OR = 7.3, P < 0.01) to be independent predictors of injury being found on imaging studies. CONCLUSIONS: Inpatient falls are common despite high-risk patients being identified. After adjusting for age and sex, evidence of trauma and ambulatory status were independent predictors of an injury being found on imaging studies after an inpatient fall. Journal of Hospital Medicine 2010;5:63,68. © 2010 Society of Hospital Medicine. [source] Rate, causes and reporting of medication errors in Jordan: nurses' perspectivesJOURNAL OF NURSING MANAGEMENT, Issue 6 2007MAJD T. MRAYYAN PhD Aim, The aim of the study was to describe Jordanian nurses' perceptions about various issues related to medication errors. Background, This is the first nursing study about medication errors in Jordan. Methods, This was a descriptive study. A convenient sample of 799 nurses from 24 hospitals was obtained. Descriptive and inferential statistics were used for data analysis. Results, Over the course of their nursing career, the average number of recalled committed medication errors per nurse was 2.2. Using incident reports, the rate of medication errors reported to nurse managers was 42.1%. Medication errors occurred mainly when medication labels/packaging were of poor quality or damaged. Nurses failed to report medication errors because they were afraid that they might be subjected to disciplinary actions or even lose their jobs. In the stepwise regression model, gender was the only predictor of medication errors in Jordan. Conclusions, Strategies to reduce or eliminate medication errors are required. [source] Patterns in nursing home medication errors: disproportionality analysis as a novel method to identify quality improvement opportunitiesPHARMACOEPIDEMIOLOGY AND DRUG SAFETY, Issue 10 2010Richard A. Hansen Abstract Purpose To explore the use of disproportionality analysis of medication error data as a novel method to identify relationships that might not be obvious through traditional analyses. This approach can supplement descriptive data and target quality improvement efforts. Methods Data came from the Medication Error Quality Initiative (MEQI) individual event reporting system. Participants were North Carolina nursing homes who submitted incident reports to the Web-based MEQI data repository during the 2006 and 2007 reporting years. Data from 206 nursing homes were summarized descriptively and then disproportionality analysis was applied. Associations between medication type and possible causes at the state level were explored. A single nursing home was selected to illustrate how the method might inform quality improvement at the facility level. Disproportionality analysis of drug errors in this home was compared with benchmarking. Results Statewide, 59 drug-cause pairs met the disproportionality signal and 11 occurred in 10 or more reports. Among these, warfarin was co-reported with communication errors; esomeprazole, risperidone, and nitrofurantoin were disproportionately associated with transcription error; and oxycodone and morphine were disproportionately reported with name confusion. Facility-level analyses illustrate how descriptive frequencies and disproportionality analysis are complementary, but also identify different safety targets. Conclusions Exploratory analysis tools can help identify medication error types that occur at disproportionate rates. Candidate associations might be used to target patient safety work, although further evaluation is needed to determine the value of this information. Copyright © 2010 John Wiley & Sons, Ltd. [source] | ||||||||||||||||||||||