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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Authors:
Patient Safety and Quality:
An Evidence-Based
Handbook for Nurses
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
540 Gaither Road
Rockville, MD 20850
Editor:
Ronda G. Hughes, Ph.D., M.H.S., R.N.
AHRQ Publication No. 08-0043
April 2008
Disclaimer: The opinions expressed in this document are those of the authors
and do not reflect the official position of AHRQ or the U.S. Department of Health
and Human Services.
This document is in the public domain and may be used and reprinted without
permission, except those copyrighted materials noted for which further reproduction is
prohibited without specific permission of the copyright holder. Citation of the source is
appreciated.
Suggested Citation:
Hughes RG (ed.). Patient safety and quality: An evidence-based handbook for nurses.
(Prepared with support from the Robert Wood Johnson Foundation). AHRQ Publication
No. 08-0043. Rockville, MD: Agency for Healthcare Research and Quality; March 2008.
ii
Foreword
The Agency for Healthcare Research and Quality (AHRQ) and the Robert Wood Johnson
Foundation (RWJF) are pleased to have jointly sponsored the development of this handbook for
nurses on patient safety and quality. Patient Safety and Quality: An Evidence-Based Handbook
for Nurses examines the broad range of issues involved in providing high quality and safe care
across health care settings.
We know that nurses are at the center of patient care and therefore are essential drivers of
quality improvement. From the Institute of Medicine’s reports, including To Err is Human and
Keeping Patient’s Safe: Transforming the Work Environment of Nurses, we know that patient
safety remains one of the most critical issues facing health care today and that nurses are the
health care professionals most likely to intercept errors and prevent harm to patients. For us, both
at AHRQ and RWJF, improving patient safety and health care quality is embedded in our
mission and at the core of what we do.
We strongly believe that the safety and quality of health care in this nation is dependent upon
the availability of the best research possible and on our ability to deliver the results of that
research into the hands of providers, policymakers, and consumers so that all can make better
decisions. We believe the result will be improved health care and safety practices, which will be
manifested in measurably better outcomes for patients.
Given the diverse scope of work within the nursing profession in this country, AHRQ and the
RWJF expect that the research and concepts presented in the book will be used to improve health
care quality by nurses in practice, nurse-educators, nurse-researchers, nursing students, and
nursing leaders. The 89 contributors to this book represent a broad range of nurse-researchers
and senior researchers throughout this nation.
The product of this joint effort underscores the commitment of AHRQ and the RWJF to
achieving a health care system that delivers higher quality care to everyone. We believe that
high-quality health care can be achieved through the use of evidence and an enabled and
empowered nursing workforce.
We welcome written comments on this book. They may be sent to Ronda Hughes, Agency
for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850.
Carolyn M. Clancy, M.D. Risa Lavizzo-Mourey, M.D., M.B.A.
Director President and CEO
Agency for Healthcare Research Robert Wood Johnson Foundation
and Quality
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Preface
Errors pervade our lives in our homes, on the roads, and in our places of work. Each hour of
each day, patients and clinicians are affected by near errors and the consequences of adverse
events. The effects of health care errors and poor quality health care have impacted all our
lives—sometimes directly, at other times indirectly. Even during the writing of this book, many
of the authors had firsthand experiences with near errors, adverse events, and a level of poor-
quality care that should never have been presented to any patient. Given the importance of health
and health care in our lives, the purpose of this book is to bring safety and quality to the forefront
in nursing.
Throughout these pages, you will find peer-reviewed discussions and reviews of a wide range
of issues and literature regarding patient safety and quality health care. Owing to the complex
nature of health care, this book provides some insight into the multiple factors that determine the
quality and safety of health care as well as patient, nurse, and systems outcomes. Each of these
51 chapters and 3 leadership vignettes presents an examination of the state of the science behind
quality and safety concepts and challenges the reader to not only use evidence to change
practices but also to actively engage in developing the evidence base to address critical
knowledge gaps. Patient safety and quality care are at the core of health care systems and
processes and are inherently dependent upon nurses. To achieve goals in patient safety and
quality, and thereby improve health care throughout this nation, nurses must assume the
leadership role.
Despite being a relatively new field of inquiry, particularly in terms of how patient safety and
quality are now defined, the need to improve the quality and safety of care is the responsibility of
all clinicians, all health care providers, and all health care leaders and managers. As clinicians,
we are obligated to do our best, regardless of whether we are acting as a clinician or a patient.
Just as we say there are “good patients” and “bad patients,” clinicians as patients can
unfortunately be considered “bad patients” because they may know too much, ask too many
questions, or are not up-to-date on the research or current practice standards. Yet that is a
mindset that must end and become a part of history, not to be repeated. Instead, nurses need to
ensure that they and other team members center health care on patients and their families. All
patients—whether they include ourselves, our loved ones, or the millions of our neighbors
throughout this country—need to be engaged with clinicians in their care.
Each of the chapters in this book is organized with a background section and analysis of the
literature. At the end of each chapter, you will find two critical components. First, there is a
“Practice Implications” section that outlines how the evidence can be used to inform practice
changes. Practice leaders and clinicians can use this information, based on the state of the
science, to guide efforts to improve the quality and safety of delivering services to patients.
Second, there is a “Research Implications” section that outlines research gaps that can be
targeted by researchers and used by clinicians to inform and guide decisions for practice. Faculty
and graduate students will find innumerable questions and issues that can be used to develop
dissertation topics and grant applications to uncover the needed evidence.
In all but a few chapters, you will find evidence tables. These tables were developed by
critically assessing the literature, when possible, and present invaluable insight as to the type and
quality of research that can inform practice, clarify knowledge gaps, and drive future research.
As the reader will observe, the majority of patient safety and quality research presented in the
evidence tables represent cross-sectional studies. In fact, 81 percent of the studies exploring the
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various aspects of safety and quality employed cross-sectional study designs, predominately
representing assessments at single sites of care and using qualitative surveys. This may be the
byproduct of the challenges of the research process (including sources of funding) or the
challenges of engaging in collaborative research. From this review of the literature, we can learn
the importance of the need for longitudinal, multisite analyses to bring us forward into the next
generation of evidence-based knowledge.
Great is the importance of nurses being involved throughout the research process and
collaborating with interdisciplinary teams throughout care settings. Then, too, it is critical that
nursing leaders and managers, clinical leaders, and nurses across care settings engage in a
lifelong pursuit of using data and information as well as research evidence to inform practice.
Combined with experiential knowledge, analyses, and evidence, nurses will be challenged to
continuously improve care processes and encourage our peers and interdisciplinary colleagues to
make sure patients receive the best possible care, regardless of where they live, their race or
gender, or their socioeconomic circumstances.
The chapters in this book are organized into six sections. Each chapter can be read
independently of the others; however, some do make reference to other chapters, and a greater
understanding of the breadth and depth of patient safety and quality can be better obtained by
reading the book in its entirety. Highlights from the chapters are summarized by section as
follows:
In Section I – Patient Safety and Quality, patient safety is discussed as being foundational to
quality, where nurses can be invaluable in preventing harm to patients and improving patients’
outcomes (chapter 1). Even though the quality and safety of health care is heavily influenced by
the complex nature of health care and multiple other factors, nurses have been held accountable
for harm to patients, even when other clinicians and health care providers and characteristics of
the care system in which they work often have—almost without exception—greater roles and, in
some respects, have ensured that an error would happen (chapters 2 and 3). With the many
challenges facing health care today, the Institute of Medicine’s 11-volume Quality Chasm series
brings to light the multitude of issues and factors that individuals and organizations, both within
and outside of nursing and health care, need to understand and to work together to overcome
(chapter 4). Moving toward and securing a culture of safety throughout health care will, by
definition, acknowledge the influence of human factors in all clinicians, the results of human-
system interfaces and system factors, and will institutionalize processes and technology that will
make near errors and errors very rare (chapter 5). This paradigm shift will enable nurses to think
more critically and clinically (chapter 6), and to achieve greater insights as to how education,
training, and experience are needed and can be leveraged to ultimately achieve high-quality care
in every care setting and for all patients.
To improve patient safety and quality, one needs to understand the state of the science at
hand, as well as strategies that can be behind effective utilization of evidence and
implementation of change, as discussed in Section II – Evidence-Based Practice. It is here that
one can learn that implementing evidence into practice can be accomplished though several
approaches—often more than one simple intervention is possible—and by early on engaging key
stakeholders to move toward adoption of change by translating research-based evidence into
everyday care (chapter 7). Yet in assessing the state of the science, it becomes apparent that the
majority of care afforded patients is not evidence based, emphasizing the need for health services
research to examine progress toward safer and higher-quality care and to assess new and
innovative practices (chapter 8). While the future of health care is uncertain, clinicians must
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continually assess, understand, and meet the needs of patients and prepare themselves to meet
emerging health needs we might not expect (chapter 9).
Due to innumerable pressures to improve patient safety and quality, it may be important to
focus on those areas of care delivery, as discussed in Section III – Patient-Centered Care, that
are significantly influenced by nursing care. Providing health care is all about patients and their
needs and meeting those care needs in settings where the majority of care is provided by
clinicians—or, in certain circumstances, where loved ones and family members supplement
nursing care or solely provide for the care needs of patients in community settings. Almost all
the adverse events and less-than-optimal care afforded patients can be prevented, beginning by
implementing research in practice. Situations in which failure to use evidence can be detected
can include when preventable patients falls with injury occur (chapter 10), when illness-related
complications are missed and lead to functional decline in the elderly (chapter 11), and when
pressure ulcers develop in patients of any age (chapter 12). For nurses, ensuring and/or providing
evidence-based, safe, and high-quality care become even more challenging when patients need
care in their homes and subsequently rely on care rendered by family members and loved ones—
care that can be dependent upon the guidance of nurses (chapter 13). Not only can the resources
and functionality of the community or home setting pose potential threats to the safety of patients
and may relegate them to care of a lower quality, but those who care for patients may also
succumb to the physical and emotional demands of providing informal care; amelioration can
require broadening nursing care to caregivers (chapter 14).
Nursing can also have a significant effect on the outcomes of specific groups of patients,
particularly in preventing not only adverse events but the lasting effects of comorbidities and
symptoms. The reason behind focusing on these specific populations is that their unique needs
must not be considered less important than those of the majority. In the case of children, who are
some of the most vulnerable patients due to developmental and dependency factors, it is difficult
to provide safe, high-quality care that meets their unique needs. Instead, nurses need to use
current best practices (chapter 15) to avert potentially lifelong comorbidities and address
symptoms—and develop new practices when the evidence is not available. It is also important to
focus on simple strategies to prevent morbidity—not just preventing adverse events—and ensure
that patients receive preventive care services whenever possible, especially when the use of these
services is supported by evidence (chapter 16). Especially for patients with moderate to severe
pain, it is also important to prevent the adverse effects of their diseases and conditions by
working with patients to manage their pain, promoting healing and improving function (chapter
17). And finally, in the case of potential adverse effects of polypharmacy in the elderly, nurses
can also focus on simple strategies to improve adherence to intended therapies and detect
unnecessary side effects, thereby improving medication safety (chapter 18).
Beyond the influence of evidence on quality processes and outcomes, there are health care
system and organization factors and characteristics to consider. As discussed in Section IV –
Working Conditions and the Work Environment for Nurses, evidence concerning the impact of
health care system factors illustrates that working conditions and the work environment, which
are heavily influenced by leaders, can have a greater impact on the safety and quality of health
care than what an individual clinician can do. Instead of aggregating the various aspects of
working conditions, the chapters in this section define and focus on specific aspects of key
factors associated with patient and systems outcomes, centering on the importance of leadership.
The leadership and management of health care organizations and health systems are pivotal
to safer and higher quality of care because they direct and influence: which model of care is used
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to organize inpatient care services for patients (chapter 19); whether or not the organization
embraces and is committed to fostering and sustaining a climate of safety and high-quality care
(chapter 21); the impact of external factors, and the functionality and organization of
microsystems within the context of the organization and relationships with others (chapter 22);
how the specific care needs of patients are met with sufficient numbers of the right types of
nurses (chapter 23 and chapter 25); how resource allocations and cost-saving strategies that
involve restructuring, mergers, and organizational turbulence impact care delivery and patient
outcomes (chapter 24 and chapter 29); the type of work environment that influences work stress
and patient outcomes (chapter 26 and chapter 27); and how the actual physical environment and
care processes influence the workload and workflow of nursing care (chapter 28, chapter 30,
chapter 31).
Taken together, leadership throughout organizations, led by nurse executives and influenced
by physicians, is critical in determining whether or not safety and high-quality care can be
achieved through daily teamwork, collaboration, and communication (chapter 20). It is because
of the importance of senior nursing leadership that emphasis is put on the moral imperative that
senior nursing leadership has to lead health care in the quest for safer and higher-quality care
(vignette a), to demonstrate the right type of leadership (vignette b), and to excel in the right
competencies (e.g., business skills and principles, communication and relationship management,
and professionalism) (vignette c).
Nursing leaders must actively work with and enable staff to transform the current work
climate and care delivery. Section V – Critical Opportunities for Patient Safety and Quality
Improvement puts forth several critical opportunities that leaders and staff can work together to
achieve success. In almost every care setting and situation, effective communication is essential.
Not only do clinicians need to constantly communicate in a professional and technical way
(chapter 32) and with team members in a way that is respectful and attuned to individual
differences (chapter 33), clinicians must also ensure that the right information is communicated
to next caregiver or health care provider so that the safety and quality of care is not compromised
(chapter 34).
Other opportunities for improvement center on the necessity to continually assess near errors
and errors, not only those events that harm patients, and put in place strategies to avert the
recurrence of both the near error and errors. Assessing and evaluating near errors and errors—
and the ability to avert the recurrence of errors—is dependent upon having information that is
reported by clinicians (chapter 35), so that some errors (e.g., wrong-site surgery) never happen
(chapter 36). Many initiatives to improve patient safety and health care quality have focused on
medication safety. While many medication errors are prevented from harming patients because a
nurse detected the error, monitoring and evaluating both near misses and adverse drug events can
lead to the adoption of strategies to decrease the opportunities for errors, including unit dosing,
using health information technology (chapter 37), and reconciling a patient’s medications
(chapter 38).
The nature of the work and the stress of caregiving can place nurses and patients at risk for
harm. Moving patients, being in close proximity to therapeutic interventions, the implications of
shift work and long work hours (chapter 39 and chapter 40), and ignoring the potential risk of
injury and the impact of fatigue can increase the risk of occupational injury. It follows then that,
because of the nature of the work, the proximity of nurses to patients, and the chronic and acute
needs of patients, particular attention must be given to preventing health care–associated
infections through known effective strategies, such as environmental cleanliness, hand hygiene,
viii
protective barriers (chapter 41), and strategies to address ventilator-acquired pneumonia (chapter
42).
The influence of nurse practitioners and of the new generation of doctorate-level nurse
clinicians has the potential of enabling significant improvements in critical opportunities for
patient safety and quality improvement (chapter 43). The opportunities to demonstrate the
influence of these clinical leaders is endless. The last section of this book, Section VI – Tools for
Quality Improvement and Patient Safety, focuses on the strategies and technologies that can be
used to push health care to the next level of quality. One of the tools that can be used is quality
methods, including continuous quality improvement, root cause analysis, and plan-do-study-act
(chapter 44). Quality and patient safety indicators can also be used to assess performance and
monitor improvement (chapter 45). These, as well as other tools, are integral in efforts to develop
and demonstrate nursing excellence (chapter 46). With recent developments in information
technologies, there are many potential benefits that can be afforded by these technologies that
can facilitate decisionmaking, communication of patient information (chapter 47, chapter 48,
chapter 49), therapeutic interventions (so long as the information technologies are used and
function properly) (chapter 49), and education and training (chapter 51).
All of these various issues and factors come together to define the complexity and scope of
patient safety and quality care but also the necessity for multifaceted strategies to create change
within health care systems and processes of care. In using evidence in practice, engaging in
initiatives to continually improve quality, and striving for excellence, nurses can capitalize on the
information from this book and lead health care in the direction that it should and needs to be
heading to better care for the needs of patients. What it all comes down to is for us, as nurses, to
decide what kind of care we would want as patients then to do all that is possible to make that
happen. Today we may be doing what we can, but tomorrow we can improve. With this evidence
and the call to action to nurses, in 5 years from now, headlines and research findings should
carry forth the message that there are significant improvements in the quality and safety of health
care throughout this nation, and it was because nurses led the way.
Ronda G. Hughes
Editor
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Peer Reviewers
Daleen Aragon—Orlando Regional
Healthcare, FL
William Baine—AHRQ, MD
Mary Barton—AHRQ, MD
Mary Blegen—University of California at
San Francisco, CA
Barbara Braden—Creighton University, NE
Nancy Bergstrom—University of Texas,
Houston, TX
Peter Bruehaus—Vanderbilt University, TN
Helen Burstin—National Quality Forum,
DC
Carol Cain—Kaiser Permante, CA
Carolyn Clancy—AHRQ, MD
Sean Clarke—University of Pennsylvania,
PA
Marilyn Chow—Kaiser Permante, CA
Beth Collins-Sharp—AHRQ, MD
Kathy Crosson—AHRQ, MD
Linda Lindsey Davis—Duke University, NC
Ellen Mockus D’Errico—Loma Linda
University, CA
Joanne Disch—University of Minnesota,
MN
Anita Hanrahan—Capital Health,
Edmonton, Alberta
Aparana Higgins—Booz | Allen | Hamilton,
NY
Kerm Henrickson—AHRQ, MD
Judith Hertz—Northern Illinois University,
IL
Ronda Hughes—AHRQ, MD
Rainu Kaushal—Harvard-Partners, MA
Ron Kaye—FDA, MD
Marge Keyes—AHRQ, MD
Christine Kovner—New York University,
NY
Jeanette Lancaster—University of Virginia,
VA
David Lanier—AHRQ, MD
Elaine Larson—Columbia University, NY
Kathy Lee—University of California at San
Francisco, CA
Michael Leonard—Kaiser Permante, CA
Sally Lusk—University of Michigan, MI
David Meyers—AHRQ, MD
Jack Needleman—University of California
at Los Angeles, CA
D.E.B. Potter—AHRQ, MD
Peter Pronovost—Johns Hopkins University,
MD
Amanda Rischbieth—Australia
Carol Romano—DHHS/USPHS, MD
Judy Sangel - AHRQ, MD
Cynthia Scalzi—University of Pennsylvania,
PA
Carol Scholle—University of Pittsburgh
Medical Center Presbyterian Hospital, PA
Jean Ann Seago—University of California
at San Francisco, CA
Joan Shaver—University of Illinois at
Chicago, IL
Maria Shirey—Shirey & Associates, IN
Jean Slutsky—AHRQ, MD
Kaye Spence—Children’s Hospital at
Westmead, Sydney, Australia
Janet Tucker—University of Aberdeen,
United Kingdom
Tasnim Vira—University of Toronto,
Ontario
Judith Warren—University of Kansas, KS
Jon White—AHRQ, MD
Zane Robinson Wolf—La Salle University,
PA
Laura Zitella—Stanford University Cancer
Center, CA
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Contributing Authors
Kathryn Rhodes Alden, M.S.N., R.N.,
I.B.C.L.C.
University of North Carolina at Chapel
Hill
Kristine Alster, Ed.D., R.N.
University of Massachusetts at Boston
Lisa Antle, A.P.R.N., B.C., A.P.N.P
University of Wisconsin Milwaukee
College of Nursing
Elizabeth A. Ayello, Ph.D., R.N., A.P.R.N.,
B.C., C.W.O.C.N., F.A.P.W.C.A.,
F.A.A.N.
Advances in Skin and Wound Care
Jane H. Barnsteiner, Ph.D., R.N., F.A.A.N.
University of Pennsylvania School of
Nursing and Hospital of the University of
Pennsylvania
Ann Bemis, M.L.S.
Rutgers, The State University of New
Jersey
Patricia Benner, R.N., Ph.D., F.A.A.N.
Carnegie Foundation for the Advancement
of Teaching
Mary A. Blegen, Ph.D., R.N., F.A.A.N.
School of Nursing, University of
California, San Francisco
Jacqueline F. Byers, Ph.D., R.N., C.N.A.A.,
C.P.H.Q.
College of Nursing, University of Central
Florida, Orlando
Carol H. Cain, Ph.D.
Care Management Institute, Kaiser
Permanente
Pascale Carayon, Ph.D.
University of Wisconsin-Madison
Claire C. Caruso, Ph.D., R.N.
National Institute for Occupational Safety
and Health
Sean P. Clarke, R.N., Ph.D., C.R.N.P.,
F.A.A.N.
University of Pennsylvania School of
Nursing
Amy S. Collins, B.S., B.S.N., M.P.H.
Centers for Disease Control and
Prevention
Karen Cox, R.N., Ph.D., C.N.A.A.,
F.A.A.N.
Children’s Mercy Hospitals and Clinics,
Kansas City, MO
Leanne Currie, D.N.Sc., M.S.N., R.N.
Columbia University School of Nursing
Margaret J. Cushman, Ph.D.(c), R.N.,
F.H.H.C., F.A.A.N.
University of Massachusetts at Boston
Maureen Ann Dailey, R.N., M.S.
Columbia University School of Nursing
Elizabeth Dayton, M.A.
Johns Hopkins University
Andrea Deickman, M.S.N., R.N.
iTelehealth Inc.
Joanne Disch, Ph.D., R.N., F.A.A.N.
University of Minnesota School of
Nursing
Molla Sloane Donaldson, Dr.P.H., M.S.
M.S.D. Healthcare
Nancy E. Donaldson, R.N., D.N.Sc.,
F.A.A.N.
University of California, San Francisco,
School of Nursing
Carol Fowler Durham, M.S.N., R.N.,
University of North Carolina at Chapel
Hill
Victoria Elfrink, Ph.D., R.N.B.C.
College of Nursing of Ohio State
University and iTelehealth Inc.
Carol Hall Ellenbecker, Ph.D., R.N.
University of Massachusetts at Boston
Marybeth Farquhar, R.N., M.S.N., C.A.G.S.
Agency for Healthcare Research and
Quality
Kathy Fletcher, R.N., G.N.P., A.P.R.N.-
B.C., F.A.A.N.
University of Virginia Health System
xii
Patient Safety and Quality: An Evidence-Based Handbook for Nurses
Mary Ann Friesen, M.S.N., R.N., C.P.H.Q.
Center for American Nurses, Silver
Spring, MD
Jeanne M. Geiger-Brown, Ph.D., R.N.
University of Maryland School of Nursing
Karen K. Giuliano, R.N., Ph.D., F.A.A.N.
Philips Medical Systems
Barbara Given, Ph.D., R.N., F.A.A.N.
Michigan State University College of
Nursing
Ayse P. Gurses
University of Minnesota-Twin Cities
Saira Haque, M.H.S.A., Doctoral candidate
Syracuse University
Kerm Henriksen, Ph.D.
Agency for Healthcare Research and
Quality
Ronda G. Hughes, Ph.D., M.H.S., R.N.
Agency for Healthcare Research and
Quality
Bonnie M. Jennings, D.N.Sc., R.N.,
F.A.A.N.
Colonel, U.S. Army (Retired) and health
care consultant
Meg Johantgen, Ph.D., R.N.
University of Maryland School of Nursing
Gail M. Keenan, Ph.D., R.N.
University of Illinois, Chicago
Margaret A. Keyes, M.A.
Agency for Healthcare Research and
Quality
Ruth M. Kleinpell, Ph.D., R.N., F.A.A.N.
Rush University College of Nursing,
Chicago, IL
Susan R. Lacey, R.N., Ph.D.
Nursing Workforce and Systems Analysis,
Children’s Mercy Hospitals and Clinics,
Kansas City, MO
Jane A. Lipscomb, Ph.D., R.N., F.A.A.N.
University of Maryland School of Nursing
Carol J. Loveland-Cherry, Ph.D., R.N.,
F.A.A.N.
University of Michigan School of Nursing
Vicki A. Lundmark, Ph.D.
American Nurses Credentialing Center
Courtney H. Lyder, N.D., G.N.P., F.A.A.N.
University of Virginia
Mary Mandeville, M.B.A.
University of Illinois, Chicago
Karen Dorman Marek, Ph.D., M.B.A., R.N.,
F.A.A.N.
University of Wisconsin Milwaukee
College of Nursing
Diana J. Mason, R.N., Ph.D., F.A.A.N.
American Journal of Nursing
Margo McCaffery, R.N., F.A.A.N.
Pain management consultant
Pamela H. Mitchell, Ph.D., R.N., C.N.R.N.,
F.A.A.N., F.A.H.A.
University of Washington School of
Nursing
Deborah F. Mulloy, M.S.N., C.N.O.R.,
Doctoral student
University of Massachusetts at Boston
School of Nursing
Cindy L. Munro, R.N., A.N.P., Ph.D.,
F.A.A.N.
Virginia Commonwealth University
School of Nursing
Mike R. Murphy, R.N., B.S.N., M.B.A.
Synergy Health/St. Joseph’s Hospital
Audrey L. Nelson, Ph.D., R.N., F.A.A.N.
James A. Haley Veterans’ Hospital,
Tampa, FL
Michelle O’Daniel, M.H.A., M.S.G.,
VHA West Coast
Eileen T. O’Grady, Ph.D., R.N., N.P.
Nurse Practitioner World News and The
American Journal for Nurse Practitioners
Ann E. K. Page, R.N., M.P.H.
Institute of Medicine
Chris Pasero, R.N.
Pain management consultant
Emily S. Patterson, Ph.D.
Cincinnati VA Medical Center and Ohio
State University
Nirvana Huhtala Petlick
Rutgers, The State University of New
Jersey
Shobha Phansalkar, R.Ph., Ph.D.
Harvard Medical School
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Contributing Authors
Sally Phillips, Ph.D., R.N.
Agency for Healthcare Research and
Quality
Gail Powell-Cope, Ph.D., A.R.N.P.,
F.A.A.N.
James A. Haley Veterans Hospital,
Tampa, FL
John Reiling, Ph.D., M.H.A., M.B.A.,
Synergy Health/St. Joseph’s Hospital
Susan C. Reinhard, Ph.D., M.S.N., F.A.A.N.
Rutgers, The State University of New
Jersey
Victoria L. Rich, Ph.D., R.N., F.A.A.N.
University of Pennsylvania Health System
Ann E. Rogers, Ph.D., R.N., F.A.A.N.
University of Pennsylvania School of
Nursing and University of Pennsylvania
School of Medicine
Alan H. Rosenstein, M.D., M.B.A.
VHA West Coast
Linda Samia, Ph.D., R.N.
Healthy Choices for ME, MaineHealth’s
Partnership for Healthy Aging
Barbara A. Sattler, R.N., Dr.P.H., F.A.A.N.
University of Maryland School of Nursing
Lucy A. Savitz, Ph.D., M.B.A.
Abt Associates
Loretta Schlachta-Fairchild, R.N., Ph.D.,
F.A.C.H.E.
iTelehealth Inc.
Jean Ann Seago, Ph.D., R.N.
School of Nursing, University of
California, San Francisco
Victoria L. Selby, R.N., B.S.N.
University of Maryland School of Nursing
Laura Senn, M.S., R.N.
University of Minnesota School of
Nursing
Janis B. Smith, R.N., M.S.N.
Children’s Mercy Hospitals and Clinics,
Kansas City, MO
Elizabeth S. Soule
University of Washington School of
Nursing
Nancy Staggers, Ph.D., R.N., F.A.A.N.
University of Utah College of Nursing and
School of Medicine
Donald Steinwachs, Ph.D.
Johns Hopkins University
Patricia W. Stone, Ph.D., M.P.H., R.N.
Columbia University School of Nursing
Molly Sutphen, Ph.D.
Carnegie Foundation for the Advancement
of Teaching
Marita G. Titler, Ph.D., R.N., F.A.A.N.
University of Iowa Hospitals and Clinics
Alison M. Trinkoff, Sc.D., R.N., F.A.A.N.
University of Maryland School of Nursing
Dana Tschannen, Ph.D., R.N.
University of Michigan.
Mary Wakefield, Ph.D., R.N., F.A.A.N.
University of North Dakota, Grand Forks
Charlene Weir, Ph.D., R.N.
VA Geriatric Research Education and
Clinical Centers, Salt Lake City, UT
Nancy Wells, D.N.Sc., R.N., F.A.A.N.
Vanderbilt Medical Center and Vanderbilt
University School of Nursing
Susan V. White, Ph.D., R.N., C.P.H.Q.,
F.N.A.H.Q.
James A. Haley Veterans’ Hospital,
Tampa, FL
Zane Robinson Wolf, Ph.D., R.N., F.A.A.N.
La Salle University School of Nursing and
Health Sciences
Elizabeth Yakel, Ph.D.
University of Michigan
xiv
Acknowledgments
Without a doubt, this could not have been accomplished without the contribution and
dedication of many people, both internally and externally to the Agency for Healthcare Research
and Quality (AHRQ). A special note of gratitude is extended to each author and peer reviewer,
who willingly shared their expertise and dedication to making health care better and safer. This
project would not have been possible without financial support from the Robert Wood Johnson
Foundation and the AHRQ, as well as the time authors committed to this project. Invaluable
support was given by Carolyn Clancy, Helen Burstin, Tonya Cooper, Susan Hassmiller, David
Lanier, and David Meyers throughout the 2-year process of bringing this project together.
Sincere gratitude is also extended to AHRQ’s Office of Communications and Knowledge
Transfer (OCKT), specifically Randie Siegel (project oversight), David I. Lewin
(copyediting/production management), and Morgan Liskinsky (marketing plan). Further
gratitude is extended to OCKT’s editorial contractors (Helen Fox, Roslyn Rosenberg, and Daniel
Robinson). Additional thanks go to Joy Solomita, of AHRQ’s Center for Primary Care,
Prevenrion, and Clinical Partnerships (CP3), for all her efforts during the finalization process.
Lastly, this book was dependent upon the invaluable assistance of Caryn McManus, Reneé
McCullough, Lynette Lilly, and other librarians throughout the country, who helped search for
and retrieve thousands of articles and book chapters.
Ronda G. Hughes
This book is dedicated to nurses everywhere.
xv
... As the evidence base in end-of-life care is ever evolving, there is a constant need for updation in the knowledge of GPs and they access training programs in end-of-life care to resolve the conflicts in their daily practice [41,88,90]. Diverse clinical practice scenarios trigger learning [91] through reflective identification of knowledge gaps in the quality of care [92]. In the process of learning, GPs gain multiple perspectives by interacting with mentors and peers in the learning environment or at work [6,61]. ...
Article
Full-text available
Background General practitioners (GPs) play a pivotal role in providing end-of-life care in the community. Although they value end-of-life care, they have apprehensions about providing care in view of the limitations in knowledge and skills in end-of-life care. This review aimed to explore, synthesise, and analyse the views of general practitioners on end-of-life care learning preferences. Methods MEDLINE, CINAHL, PsycINFO, EMBASE, Scopus, Web of Science, and Cochrane were searched for literature on the views of general practitioners on end-of-life care learning preferences from 01/01/1990 to 31/05/2021. Methodological quality was reported. Results Of the 10,037 articles identified, 23 were included for the review. Five themes developed from the review. The desire to provide palliative care, as well as self-actualisation needs, relevance to practice, a sense of responsibility, and a therapeutic bond, motivates general practitioners to learn end-of-life care. Some of the learning needs expressed were pain and symptom management, communication skills, and addressing caregiver needs. Experiential learning and pragmatist learning styles were preferred learning styles. They perceived the need for an amicable learning environment in which they could freely express their deficiencies. The review also identified barriers to learning, challenges at personal and professional level, feelings of disempowerment, and conflicts in care. Conclusion GPs’ preference for learning about end-of-life care was influenced by the value attributed to learning, context and content, as well as preference for learning styles and the availability of resources. Thus, future trainings must be in alignment with the GPs’ learning preferences.
... It is of crucial importance that the units have competent staff (experienced MD/psychiatrist) that have the knowledge needed to prescribe appropriate medical treatment and to evaluate and adjust the treatment according to feedback from the patient and observations by staff. Skilled nursing staff are also needed to uphold good routines in medication dispensing, in communicating with patients, and in making necessary observations [34]. A lack of highly educated and skilled staff is a challenge in some Norwegian institutions, especially outside of the major cities. ...
... Patients should be viewed as shared decision-makers on the use of medication, and health care professionals need to encourage and support patients and their families to disclose all the medications they are taking, including over-the-counter, traditional and complementary medicines, especially if they are suffering from multiple conditions and are being treated with polypharmacy (27)(28)(29). Family physicians and pharmacists should conduct medication reviews and medication reconciliation whenever possible in collaboration with the patient and their families, which has a positive impact on optimizing medicine use and improving health outcomes (30)(31)(32). The effect evaluation of P value † <0.0001 0.14 -*P value means the differences between two groups. ...
Article
Full-text available
Background As one of the countries with the most serious degree of aging, the incidence of potentially inappropriate drug use among the elderly is as high as 30. 4% in Chinese communities, and the lack of effective medication management and poor medication compliance at home are the main factors. Given these situations, we constructed a Rational Medication Management Mode based on family physician service, carried out an empirical research and evaluated the implementation effect. Methods A prospective cohort study was conducted from September to December 2021 to analyze the implementation effect of the Rational Medication Management Mode by comparing the outcome indicators between the intervention group and control group. The primary outcome of this study was medication number and polypharmacy (taking 5 or more medications) at 90 days. The secondary outcomes included the situation for behavioral self-management and knowledge-belief-behavior of rational medication use. Results A total of 618 elderly patients (309 in the intervention group and 309 in the control group) with multimorbidity were included in this study, those were all available at follow-up at 90 days. At 90 days, the number of medications was achieved by 3.88 (1.48), and patients with polypharmacy were reduced by 59.55% in the intervention group, having a significant difference compared with the control group ( P < 0.001). Patients with medication reminders, intermittent medication and adverse drug reactions were achieved in 294 (95.15%), 47 (15.21%), and 51 (16.51%) respectively in the intervention group ( P < 0.001). The knowledge, belief, behavior security and behavior compliance of rational medication use of elderly patients were all greatly improved in the intervention group at 90 days ( P < 0.0001). Conclusion The Rational Medication Management Mode based family physician service, which provides the support of manuals and pillboxes, can decrease the elderly patients' number of drugs with multimorbidity, reduce the incidence of polypharmacy, enhance behavioral self-management, increase the knowledge and belief of rational medication use, and improve the security and compliance of medication usage behavior. In order to provide a practical basis for rational medication management of elderly patients with multimorbidity under the background of long-term prescriptions in China.
... The contribution of nurses, in particular, to keeping the public safe during COVID-19 has been widely recognised, helping to reinforce images of nurses as heroes and angels that have proliferated the public discourse for decades [11]. However, the pandemic emerged at a time when the nursing workforce in the UK was already under significant strain, with increased burnout, reduced job satisfaction, and problems of recruitment and retention fuelled by staff and infrastructure shortages, inadequate pay structures and opportunities for career progression, racial inequalities, and chronic, excessive workloads [12,13]. The pandemic further exacerbated existing workforce supply issues, and the number of nurses leaving the profession in the UK has started to rise [14]. ...
Article
Full-text available
The COVID-19 pandemic increased pressure on a nursing workforce already facing high levels of stress, burnout, and fatigue in the United Kingdom (UK) and internationally. The contribution of nurses to keeping the public safe was widely recognised as they met the challenges of delivering complex patient care during the healthcare crisis. However, the psychological impact of this on nurses’ health and wellbeing has been substantial, and the number of nurses leaving the profession in the UK is rising. The aim of this study was to explore the experiences of nurses working during the COVID-19 pandemic and the impact of this on their psychological health, wellbeing and resilience. The study is part of a wider project to develop and pilot an online resilience intervention for nurses during COVID-19. Five focus groups with 22 nurses were carried out online. Data was analysed thematically using the Framework Method. Four key themes relating to positive and negative impacts of working during the pandemic were identified: Rapid changes and contexts in flux; loss and disruption; finding opportunities and positive transformation; and reinforcing and strengthening identity. Implications for coping and resilience in nursing, nursing identities and workforce development are discussed.
... It is of crucial importance that the units have competent staff (experienced MD/psychiatrist) that have the knowledge needed to prescribe appropriate medical treatment and to evaluate and adjust the treatment according to feedback from the patient and observations by staff. Skilled nursing staff are also needed to uphold good routines in medication dispensing, in communicating with patients, and in making necessary observations [34]. A lack of highly educated and skilled staff is a challenge in some Norwegian institutions, especially outside of the major cities. ...
Article
Full-text available
Underlying patterns and factors behind suicides of patients in treatment are still unclear and there is a pressing need for more studies to address this knowledge gap. We analysed 278 cases of suicide reported to The Norwegian System of Patient Injury Compensation, drawing on anonymised data, i.e., age group, gender, diagnostic category, type of treatment provided, inpatient vs. outpatient status, type of treatment facility, and expert assessments of medical errors. The data originated from compensation claim forms, expert assessments, and medical records. Chi-square tests for independence, multinominal logistic regression, and Bayes factors for independence were used to analyse whether the age group, gender, diagnostic category, inpatient/outpatient status, type of institution, and type of treatment received by patients that had died by suicide were associated with different types of medical errors. Patients who received medication tended to be proportionally more exposed to an insufficient level of observation. Those who received medication and psychotherapy tended to be proportionally more exposed to inadequate treatment, including inadequate medication. Inpatients were more likely to be exposed to inappropriate diagnostics and inadequate treatment and follow up while outpatients to insufficient level of observation and inadequate suicide risk assessment. We conclude that the patients who had received medication as their main treatment tended to have been insufficiently observed, while patients who had received psychotherapy and medication tended to have been provided insufficient treatment, including inadequate medication. These observations may be used as learning points for the suicide prevention of patients in treatment in Norwegian psychiatric services.
... To achieve an efficient and quality health system, the patient safety becomes a constitutive element of the care process as the quality of care cannot exist without patient safety (5). ...
Article
Full-text available
Today, health systems are complex due to both the technological development in diagnostic and therapeutic procedures and the complexity of the patients that are increasingly older with several comorbidities. In any care setting, latent, organizational, and systematic errors can occur causing critical incident harmful for patients. Management of patients with acute kidney injury (AKI) requires a multidisciplinary approach for the diagnostic-therapeutic-rehabilitative path that can also require an extracorporeal blood purification treatment (EBPT). The complexity of these patients and EBPT require a clinical risk analysis and the introduction of protocols, procedures, operating instructions, and checklists to reduce clinical risk through promotion of the safety culture for all care providers. Caregivers must acquire a series of tools to evaluate the clinical risk in their reality to prevent incidents and customize patient safety in a proactive and reactive way. Established procedures that are made more needed by the COVID-19 pandemic can help to better manage patients in critical care area with intrinsic higher clinical risk. This review analyzes the communication and organizational aspects that need to be taken into consideration in the management of EBPT in a critical care setting by providing tools that can be used to reduce the clinical risk. This review is mostly addressed to all the caregivers involved in the EBPT in Critical Care Nephrology and in the Intensive Care Units.
Article
Full-text available
Aim Guided by the social embeddedness model of thriving at work, this paper explores how nursing organizational culture, work engagement and affective commitment affect nurses' thriving at work. Background Thriving at work has implications for better employee and organization outcomes. The antecedents of thriving at work among the nursing population needs to be expanded by analysing the cross‐level impact of organizational and individual characteristics. Methods A cross‐sectional design was used to collect data from 1437 frontline nurses in a tertiary teaching hospital in China between April and May 2020 through an online survey about perceived nursing culture, work engagement, affective commitment and thriving at work. Data were analysed using SPSS, and a structural equation model was established using the PROCESS macro. Results Our results showed that work engagement and affective commitment mediated the relationship between nurses' perceived nursing culture and their thriving at work. Among nurses, work engagement was positively correlated to affective commitment. Conclusion Our study confirmed the social embeddedness model of thriving at work by showing that both contextual and dispositional factors can influence nurses' thriving at work. Nurse leaders can foster nursing staff's thriving at work by building an inclusive work environment and by providing adequate resources to staff. Future research is needed to elaborate on employee and organizational outcomes associated with thriving at work. Impact Nurse leaders should be the advocate for nurses to improve their organizational identification, fostering their thriving at work. Individual nurses can also take an active role in developing work‐related resources to sustain their thriving through self‐adaption processes. Collective thriving in the nursing workforce is needed to overcome adversity and hardship in the ever‐changing and increasingly demanding health care industry and to further contribute to the vitality of the broader social and public environments. Patient or public contribution No patient or public contribution. This study did not involve patients, service users, caregivers or members of the public.
Article
Full-text available
Aims Diagnostic Reasoning (DR) is an essential competency requiring mastery for safe, independent Nurse Practitioner (NP) practice, but little is known about DR content included in NP education programs. The aims of this study were to identify whether and how the concept of DR is addressed in NP education. Design We conducted a scoping review on DR‐related content and teaching innovations in U.S. primary care NP education programs, with implications for NP education programs worldwide. Concepts and principles with global applicability include: conducting focused and hypothesis‐directed histories and exams, generating the problem statement, formulating the differential diagnosis, appropriate and relevant diagnostic testing, determining the working diagnosis and developing evidence‐based, patient‐centred management plans. Data sources N = 1115 articles retrieved from Medline, Embase, PsycINFO, and CINAHL for the period 2005–2021. Forty‐one scholarly articles met inclusion/exclusion criteria. Review methods Data were extracted, synthesized and grouped by theoretical frameworks, content included, educational interventions and assessment measures. Results Most articles provided descriptions of approaches for teaching NP clinical or diagnostic reasoning. Ten papers directly referenced the current science and theory of DR. Conclusion The US NP education literature addressing DR is limited and demonstrates a lack of shared conceptualizations of DR. Whilst numerous components of DR are identifiable in the literature, a robust teaching/learning scholarship for DR has not yet been established in the US NP education literature. Impact Whilst primary care NP education programs are beginning to incorporate DR education into their curricula, little research has been conducted to demonstrate the effectiveness of educational outcomes. Increased integration of DR content into NP education is needed, including increased educational research on teaching DR competencies. Patient or public contribution No patient or public contribution was included in this review, as the public is generally not familiar with DR or its teaching approaches.
Chapter
With the advancement of artificial intelligence, robots have entered the healthcare field and provided various intelligent services. Compared to the growing number of use cases for healthcare robots, conceptual, and theoretical research on healthcare robots is still in its infancy. There is a need to explore how healthcare robots play different roles in society with the improvement of AI technology. To fill in this research gap, we provide a conceptualization of healthcare robots and a summary of main categories of healthcare robots in previous research. This study provides a classification of healthcare robots according to their service roles and discusses their differences in different dimensions, including appearance, presence, AI and automation ability, and social ability. Finally, we propose future research directions based on the discussion to provide insights into the conceptualization of healthcare robots. This study contributes to IS literature by providing a comprehensive knowledge base for further theory-building processes of AI-based healthcare robots and providing design guidance to robotic designers in specific healthcare fields.KeywordsHealthcare robotsArtificial intelligenceClassificationService roles
Children's Mercy Hospitals and Clinics, Kansas City
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  • Md Mary Barton—ahrq
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x Peer Reviewers Daleen Aragon—Orlando Regional Healthcare, FL William Baine—AHRQ, MD Mary Barton—AHRQ, MD Mary Blegen—University of California at San Francisco, CA Barbara Braden—Creighton University, NE Nancy Bergstrom—University of Texas, Houston, TX Peter Bruehaus—Vanderbilt University, TN Helen Burstin—National Quality Forum, DC Carol Cain—Kaiser Permante, CA Carolyn Clancy—AHRQ, MD Sean Clarke—University of Pennsylvania, PA Marilyn Chow—Kaiser Permante, CA Beth Collins-Sharp—AHRQ, MD Kathy Crosson—AHRQ, MD Linda Lindsey Davis—Duke University, NC Ellen Mockus D'Errico—Loma Linda University, CA Joanne Disch—University of Minnesota, MN Anita Hanrahan—Capital Health, Edmonton, Alberta Aparana Higgins—Booz | Allen | Hamilton, NY Kerm Henrickson—AHRQ, MD Judith Hertz—Northern Illinois University, IL Ronda Hughes—AHRQ, MD Rainu Kaushal—Harvard-Partners, MA Ron Kaye—FDA, MD Marge Keyes—AHRQ, MD Christine Kovner—New York University, NY Jeanette Lancaster—University of Virginia, VA David Lanier—AHRQ, MD Elaine Larson—Columbia University, NY Kathy Lee—University of California at San Francisco, CA Michael Leonard—Kaiser Permante, CA Sally Lusk—University of Michigan, MI David Meyers—AHRQ, MD Jack Needleman—University of California at Los Angeles, CA D.E.B. Potter—AHRQ, MD Peter Pronovost—Johns Hopkins University, MD Amanda Rischbieth—Australia Carol Romano—DHHS/USPHS, MD Judy Sangel -AHRQ, MD Cynthia Scalzi—University of Pennsylvania, PA Carol Scholle—University of Pittsburgh Medical Center Presbyterian Hospital, PA Jean Ann Seago—University of California at San Francisco, CA Joan Shaver—University of Illinois at Chicago, IL Maria Shirey—Shirey & Associates, IN Jean Slutsky—AHRQ, MD Kaye Spence—Children's Hospital at Westmead, Sydney, Australia Janet Tucker—University of Aberdeen, United Kingdom Tasnim Vira—University of Toronto, Ontario Judith Warren—University of Kansas, KS Jon White—AHRQ, MD Zane Robinson Wolf—La Salle University, PA Laura Zitella—Stanford University Cancer Center, CA xi Contributing Authors Kathryn Rhodes Alden, M.S.N., R.N., I.B.C.L.C. University of North Carolina at Chapel Hill Kristine Alster, Ed.D., R.N. University of Massachusetts at Boston Lisa Antle, A.P.R.N., B.C., A.P.N.P University of Wisconsin Milwaukee College of Nursing Elizabeth A. Ayello, Ph.D., R.N., A.P.R.N., B.C., C.W.O.C.N., F.A.P.W.C.A., F.A.A.N. Advances in Skin and Wound Care Jane H. Barnsteiner, Ph.D., R.N., F.A.A.N. University of Pennsylvania School of Nursing and Hospital of the University of Pennsylvania Ann Bemis, M.L.S. Rutgers, The State University of New Jersey Patricia Benner, R.N., Ph.D., F.A.A.N. Carnegie Foundation for the Advancement of Teaching Mary A. Blegen, Ph.D., R.N., F.A.A.N. School of Nursing, University of California, San Francisco Jacqueline F. Byers, Ph.D., R.N., C.N.A.A., C.P.H.Q. College of Nursing, University of Central Florida, Orlando Carol H. Cain, Ph.D. Care Management Institute, Kaiser Permanente Pascale Carayon, Ph.D. University of Wisconsin-Madison Claire C. Caruso, Ph.D., R.N. National Institute for Occupational Safety and Health Sean P. Clarke, R.N., Ph.D., C.R.N.P., F.A.A.N. University of Pennsylvania School of Nursing Amy S. Collins, B.S., B.S.N., M.P.H. Centers for Disease Control and Prevention Karen Cox, R.N., Ph.D., C.N.A.A., F.A.A.N. Children's Mercy Hospitals and Clinics, Kansas City, MO Leanne Currie, D.N.Sc., M.S.N., R.N. Columbia University School of Nursing Margaret J. Cushman, Ph.D.(c), R.N., F.H.H.C., F.A.A.N. University of Massachusetts at Boston Maureen Ann Dailey, R.N., M.S. Columbia University School of Nursing Elizabeth Dayton, M.A. Johns Hopkins University Andrea Deickman, M.S.N., R.N. iTelehealth Inc. Joanne Disch, Ph.D., R.N., F.A.A.N. University of Minnesota School of Nursing Molla Sloane Donaldson, Dr.P.H., M.S. M.S.D. Healthcare Nancy E. Donaldson, R.N., D.N.Sc., F.A.A.N. University of California, San Francisco, School of Nursing Carol Fowler Durham, M.S.N., R.N., University of North Carolina at Chapel Hill Victoria Elfrink, Ph.D., R.N.B.C. College of Nursing of Ohio State University and iTelehealth Inc. Carol Hall Ellenbecker, Ph.D., R.N. University of Massachusetts at Boston Marybeth Farquhar, R.N., M.S.N., C.A.G.S. Agency for Healthcare Research and Quality Kathy Fletcher, R.N., G.N.P., A.P.R.N.-B.C., F.A.A.N. University of Virginia Health System xii Patient Safety and Quality: An Evidence-Based Handbook for Nurses Mary Ann Friesen, M.S.N., R.N., C.P.H.Q. Center for American Nurses, Silver Spring, MD Jeanne M. Geiger-Brown, Ph.D., R.N. University of Maryland School of Nursing Karen K. Giuliano, R.N., Ph.D., F.A.A.N. Philips Medical Systems Barbara Given, Ph.D., R.N., F.A.A.N. Michigan State University College of Nursing Ayse P. Gurses University of Minnesota-Twin Cities Saira Haque, M.H.S.A., Doctoral candidate Syracuse University Kerm Henriksen, Ph.D. Agency for Healthcare Research and Quality Ronda G. Hughes, Ph.D., M.H.S., R.N. Agency for Healthcare Research and Quality Bonnie M. Jennings, D.N.Sc., R.N., F.A.A.N.
Nursing Workforce and Systems Analysis, Children's Mercy Hospitals and Clinics, Kansas City Nurse Practitioner World News and The American Journal for Nurse Practitioners Healthy Choices for ME, MaineHealth's Partnership for Healthy Aging
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  • F N A H Q A James
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Colonel, U.S. Army (Retired) and health care consultant Meg Johantgen, Ph.D., R.N. University of Maryland School of Nursing Gail M. Keenan, Ph.D., R.N. University of Illinois, Chicago Margaret A. Keyes, M.A. Agency for Healthcare Research and Quality Ruth M. Kleinpell, Ph.D., R.N., F.A.A.N. Rush University College of Nursing, Chicago, IL Susan R. Lacey, R.N., Ph.D. Nursing Workforce and Systems Analysis, Children's Mercy Hospitals and Clinics, Kansas City, MO Jane A. Lipscomb, Ph.D., R.N., F.A.A.N. University of Maryland School of Nursing Carol J. Loveland-Cherry, Ph.D., R.N., F.A.A.N. University of Michigan School of Nursing Vicki A. Lundmark, Ph.D. American Nurses Credentialing Center Courtney H. Lyder, N.D., G.N.P., F.A.A.N. University of Virginia Mary Mandeville, M.B.A. University of Illinois, Chicago Karen Dorman Marek, Ph.D., M.B.A., R.N., F.A.A.N. University of Wisconsin Milwaukee College of Nursing Diana J. Mason, R.N., Ph.D., F.A.A.N. American Journal of Nursing Margo McCaffery, R.N., F.A.A.N. Pain management consultant Pamela H. Mitchell, Ph.D., R.N., C.N.R.N., F.A.A.N., F.A.H.A. University of Washington School of Nursing Deborah F. Mulloy, M.S.N., C.N.O.R., Doctoral student University of Massachusetts at Boston School of Nursing Cindy L. Munro, R.N., A.N.P., Ph.D., F.A.A.N. Virginia Commonwealth University School of Nursing Mike R. Murphy, R.N., B.S.N., M.B.A. Synergy Health/St. Joseph's Hospital Audrey L. Nelson, Ph.D., R.N., F.A.A.N. James A. Haley Veterans' Hospital, Tampa, FL Michelle O'Daniel, M.H.A., M.S.G., VHA West Coast Eileen T. O'Grady, Ph.D., R.N., N.P. Nurse Practitioner World News and The American Journal for Nurse Practitioners Ann E. K. Page, R.N., M.P.H. Institute of Medicine Chris Pasero, R.N. Pain management consultant Emily S. Patterson, Ph.D. Cincinnati VA Medical Center and Ohio State University Nirvana Huhtala Petlick Rutgers, The State University of New Jersey Shobha Phansalkar, R.Ph., Ph.D. Harvard Medical School xiii Contributing Authors Sally Phillips, Ph.D., R.N. Agency for Healthcare Research and Quality Gail Powell-Cope, Ph.D., A.R.N.P., F.A.A.N. James A. Haley Veterans Hospital, Tampa, FL John Reiling, Ph.D., M.H.A., M.B.A., Synergy Health/St. Joseph's Hospital Susan C. Reinhard, Ph.D., M.S.N., F.A.A.N. Rutgers, The State University of New Jersey Victoria L. Rich, Ph.D., R.N., F.A.A.N. University of Pennsylvania Health System Ann E. Rogers, Ph.D., R.N., F.A.A.N. University of Pennsylvania School of Nursing and University of Pennsylvania School of Medicine Alan H. Rosenstein, M.D., M.B.A. VHA West Coast Linda Samia, Ph.D., R.N. Healthy Choices for ME, MaineHealth's Partnership for Healthy Aging Barbara A. Sattler, R.N., Dr.P.H., F.A.A.N. University of Maryland School of Nursing Lucy A. Savitz, Ph.D., M.B.A. Abt Associates Loretta Schlachta-Fairchild, R.N., Ph.D., F.A.C.H.E. iTelehealth Inc. Jean Ann Seago, Ph.D., R.N. School of Nursing, University of California, San Francisco Victoria L. Selby, R.N., B.S.N. University of Maryland School of Nursing Laura Senn, M.S., R.N. University of Minnesota School of Nursing Janis B. Smith, R.N., M.S.N. Children's Mercy Hospitals and Clinics, Kansas City, MO Elizabeth S. Soule University of Washington School of Nursing Nancy Staggers, Ph.D., R.N., F.A.A.N. University of Utah College of Nursing and School of Medicine Donald Steinwachs, Ph.D. Johns Hopkins University Patricia W. Stone, Ph.D., M.P.H., R.N. Columbia University School of Nursing Molly Sutphen, Ph.D. Carnegie Foundation for the Advancement of Teaching Marita G. Titler, Ph.D., R.N., F.A.A.N. University of Iowa Hospitals and Clinics Alison M. Trinkoff, Sc.D., R.N., F.A.A.N. University of Maryland School of Nursing Dana Tschannen, Ph.D., R.N. University of Michigan. Mary Wakefield, Ph.D., R.N., F.A.A.N. University of North Dakota, Grand Forks Charlene Weir, Ph.D., R.N. VA Geriatric Research Education and Clinical Centers, Salt Lake City, UT Nancy Wells, D.N.Sc., R.N., F.A.A.N. Vanderbilt Medical Center and Vanderbilt University School of Nursing Susan V. White, Ph.D., R.N., C.P.H.Q., F.N.A.H.Q. James A. Haley Veterans' Hospital, Tampa, FL Zane Robinson Wolf, Ph.D., R.N., F.A.A.N. La Salle University School of Nursing and Health Sciences Elizabeth Yakel, Ph.D. University of Michigan
Advances in Skin and Wound Care
  • Authors Kathryn Rhodes Alden
  • I B C L C D Ed
  • R N University
  • A P R N Massachusetts At Boston Lisa Antle
Authors Kathryn Rhodes Alden, M.S.N., R.N., I.B.C.L.C. University of North Carolina at Chapel Hill Kristine Alster, Ed.D., R.N. University of Massachusetts at Boston Lisa Antle, A.P.R.N., B.C., A.P.N.P University of Wisconsin Milwaukee College of Nursing Elizabeth A. Ayello, Ph.D., R.N., A.P.R.N., B.C., C.W.O.C.N., F.A.P.W.C.A., F.A.A.N. Advances in Skin and Wound Care
Michigan State University College of Nursing Ayse P. Gurses University of Minnesota-Twin Cities Saira Army (Retired) and health care consultant
  • Jeanne M Geiger-Brown
  • R N K Karen
  • R N Giuliano
  • F D A A N Ph
  • Philips Medical Systems Barbara Given
  • R D N Ph
  • F A A N Haque
  • M H S A D Ph
  • Agency For Healthcare
  • Quality Research
  • G Ronda
  • Ph D Hughes
  • R N Agency For Healthcare
  • Quality Research
  • M Bonnie
  • D N Jennings
  • R N Sc
  • F A A N Colonel
  • U S M Gail
  • Ph D Keenan
Jeanne M. Geiger-Brown, Ph.D., R.N. University of Maryland School of Nursing Karen K. Giuliano, R.N., Ph.D., F.A.A.N. Philips Medical Systems Barbara Given, Ph.D., R.N., F.A.A.N. Michigan State University College of Nursing Ayse P. Gurses University of Minnesota-Twin Cities Saira Haque, M.H.S.A., Doctoral candidate Syracuse University Kerm Henriksen, Ph.D. Agency for Healthcare Research and Quality Ronda G. Hughes, Ph.D., M.H.S., R.N. Agency for Healthcare Research and Quality Bonnie M. Jennings, D.N.Sc., R.N., F.A.A.N. Colonel, U.S. Army (Retired) and health care consultant Meg Johantgen, Ph.D., R.N. University of Maryland School of Nursing Gail M. Keenan, Ph.D., R.N. University of Illinois, Chicago Margaret A. Keyes, M.A. Agency for Healthcare Research and Quality Ruth M. Kleinpell, Ph.D., R.N., F.A.A.N. Rush University College of Nursing, Chicago, IL Susan R. Lacey, R.N., Ph.D. Nursing Workforce and Systems Analysis, Children's Mercy Hospitals and Clinics, Kansas City, MO
Carnegie Foundation for the Advancement of Teaching Mary A
  • Jane H Barnsteiner
  • F A A N M L S Rutgers
  • R N D Ph
  • F A A N Blegen
Jane H. Barnsteiner, Ph.D., R.N., F.A.A.N. University of Pennsylvania School of Nursing and Hospital of the University of Pennsylvania Ann Bemis, M.L.S. Rutgers, The State University of New Jersey Patricia Benner, R.N., Ph.D., F.A.A.N. Carnegie Foundation for the Advancement of Teaching Mary A. Blegen, Ph.D., R.N., F.A.A.N. School of Nursing, University of California, San Francisco Jacqueline F. Byers, Ph.D., R.N., C.N.A.A., C.P.H.Q. College of Nursing, University of Central Florida, Orlando Carol H. Cain, Ph.D. Care Management Institute, Kaiser Permanente Pascale Carayon, Ph.D. University of Wisconsin-Madison Claire C. Caruso, Ph.D., R.N. National Institute for Occupational Safety and Health Sean P. Clarke, R.N., Ph.D., C.R.N.P., F.A.A.N. University of Pennsylvania School of Nursing
Healthy Choices for ME, MaineHealth's Partnership for Healthy
  • Alan H Rosenstein
  • M B A Vha West Coast Linda Samia
  • R N Barbara
  • A Sattler
  • R N P H Dr
Alan H. Rosenstein, M.D., M.B.A. VHA West Coast Linda Samia, Ph.D., R.N. Healthy Choices for ME, MaineHealth's Partnership for Healthy Aging Barbara A. Sattler, R.N., Dr.P.H., F.A.A.N. University of Maryland School of Nursing Lucy A. Savitz, Ph.D., M.B.A. Abt Associates Loretta Schlachta-Fairchild, R.N., Ph.D., F.A.C.H.E. iTelehealth Inc.
Children's Mercy Hospitals and Clinics
  • Amy S Collins
  • M P H Centers
  • Disease Control And Prevention Karen Cox
  • R N D Ph
  • F A A N Leanne Currie
  • D N Sc
  • R N Inc
Amy S. Collins, B.S., B.S.N., M.P.H. Centers for Disease Control and Prevention Karen Cox, R.N., Ph.D., C.N.A.A., F.A.A.N. Children's Mercy Hospitals and Clinics, Kansas City, MO Leanne Currie, D.N.Sc., M.S.N., R.N. Columbia University School of Nursing Margaret J. Cushman, Ph.D.(c), R.N., F.H.H.C., F.A.A.N. University of Massachusetts at Boston Maureen Ann Dailey, R.N., M.S. Columbia University School of Nursing Elizabeth Dayton, M.A. Johns Hopkins University Andrea Deickman, M.S.N., R.N. iTelehealth Inc.
Synergy Health/St. Joseph's Hospital
  • Sally Phillips
  • R N Agency For Healthcare
  • Quality Gail Research
  • Ph D Powell-Cope
  • F A A N James
  • A Haley Veterans
  • Hospital
  • Tampa
  • Ph D Fl John Reiling
Sally Phillips, Ph.D., R.N. Agency for Healthcare Research and Quality Gail Powell-Cope, Ph.D., A.R.N.P., F.A.A.N. James A. Haley Veterans Hospital, Tampa, FL John Reiling, Ph.D., M.H.A., M.B.A., Synergy Health/St. Joseph's Hospital Susan C. Reinhard, Ph.D., M.S.N., F.A.A.N. Rutgers, The State University of New Jersey Victoria L. Rich, Ph.D., R.N., F.A.A.N. University of Pennsylvania Health System
University of Wisconsin Milwaukee College of Nursing
  • Jane A Lipscomb
  • F A A N Carol
  • J Loveland-Cherry
  • F A A N J Diana
  • R N Mason
  • F D A A N Ph
  • R N Margo Mccaffery
  • F A A N Pain
  • Pamela H Mitchell
  • C N O R L Audrey
  • Ph D Nelson
  • F A A N James
  • A Haley Veterans 'hospital
  • Tampa
Jane A. Lipscomb, Ph.D., R.N., F.A.A.N. University of Maryland School of Nursing Carol J. Loveland-Cherry, Ph.D., R.N., F.A.A.N. University of Michigan School of Nursing Vicki A. Lundmark, Ph.D. American Nurses Credentialing Center Courtney H. Lyder, N.D., G.N.P., F.A.A.N. University of Virginia Mary Mandeville, M.B.A. University of Illinois, Chicago Karen Dorman Marek, Ph.D., M.B.A., R.N., F.A.A.N. University of Wisconsin Milwaukee College of Nursing Diana J. Mason, R.N., Ph.D., F.A.A.N. American Journal of Nursing Margo McCaffery, R.N., F.A.A.N. Pain management consultant Pamela H. Mitchell, Ph.D., R.N., C.N.R.N., F.A.A.N., F.A.H.A. University of Washington School of Nursing Deborah F. Mulloy, M.S.N., C.N.O.R., Doctoral student University of Massachusetts at Boston School of Nursing Cindy L. Munro, R.N., A.N.P., Ph.D., F.A.A.N. Virginia Commonwealth University School of Nursing Mike R. Murphy, R.N., B.S.N., M.B.A. Synergy Health/St. Joseph's Hospital Audrey L. Nelson, Ph.D., R.N., F.A.A.N. James A. Haley Veterans' Hospital, Tampa, FL Michelle O'Daniel, M.H.A., M.S.G., VHA West Coast Eileen T. O'Grady, Ph.D., R.N., N.P. Nurse Practitioner World News and The American Journal for Nurse Practitioners Ann E. K. Page, R.N., M.P.H. Institute of Medicine Chris Pasero, R.N. Pain management consultant Emily S. Patterson, Ph.D. Cincinnati VA Medical Center and Ohio State University Nirvana Huhtala Petlick Rutgers, The State University of New Jersey Shobha Phansalkar, R.Ph., Ph.D. Harvard Medical School xiii Contributing Authors
VA Geriatric Research Education and Clinical Centers
  • Mary Wakefield
  • F A A N University Of North Dakota
  • Charlene Weir
  • R N Wells
  • D N Sc
Mary Wakefield, Ph.D., R.N., F.A.A.N. University of North Dakota, Grand Forks Charlene Weir, Ph.D., R.N. VA Geriatric Research Education and Clinical Centers, Salt Lake City, UT Nancy Wells, D.N.Sc., R.N., F.A.A.N. Vanderbilt Medical Center and Vanderbilt University School of Nursing Susan V. White, Ph.D., R.N., C.P.H.Q., F.N.A.H.Q. James A. Haley Veterans' Hospital, Tampa, FL