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Knowledge Repository

Communication: patient safety and the nursing work environment

Author(s): Friesen, M.A., Hughes, R.G., Zorn, M.

Why do patients in acute care hospitals fall? Can falls be prevented?

Author(s): Dykes, P. C., Carroll, D. L., Hurley, A. C., Benoit, A., Middleton, B.
Despite a large quantitative evidence base for guiding fall risk assessment and not needing highly technical, scarce, or expensive equipment to prevent falls, falls are serious problems in hospitals.
Key Point Summary

Pod Nursing on a Medical/Surgical Unit

Author(s): Friese, C. R., Grunawalt, J. C., Bhullar, S., Bihlmeyer, K., Chang, R., & Wood, W.
The project reported in this article uses a Pod Nursing (PN) care delivery model to enhance patient-nurse proximity and a team-based patient assignment to improve select nurse and patient outcomes.
Key Point Summary

Applying root cause analysis to improve patient safety: decreasing falls in postpartum women.

Author(s): Chen, K. H., Chen, L. R., Su, S.
The objective of this study was to investigate the effectiveness of interventions to prevent falls designed through hazard analysis using root cause analysis.
Key Point Summary

Innovation Pilot Study: Acute Care for Elderly (ACE) Unit--Promoting Patient-Centric Care

Author(s): Krall et al.
Older patients have different needs: cognitive impairment, chronic health issues, caregiver burden, and maintenance of functional level. These issues present challenges to healthcare organizations when caring for this population on a general medical-surgical unit. 
Key Point Summary

Exploring Safety and Quality In a Hemodialysis Environment With Participatory Photographic Methods: A Restorative Approach.

Author(s): Marck, P., Molzahn, A., Berry-Hauf, R., Hutchings, L. G., Hughes, S.
The authors indicate that hemodialysis units can be fraught with numerous safety issues related to medication errors, lapses in communication, patient falls, equipment issues, infection control, etc. These issues can be critical in high-acuity units. This study used qualitative methods to identify existing and potential safety issues in a hemodialysis unit in a tertiary care hospital in Canada.
Key Point Summary

Adding additional grab bars as a possible strategy for safer hospital stays

Author(s): Tzeng, H.-M., Yin, C.-Y., Schechtman,S.
Inpatient falls are the most commonly reported incidents in hospitals, yet they are largely avoidable and, therefore, an unsolved issue in patient care. It comes as no surprise that patient falls tend to occur most frequently in patient rooms, patient bathrooms, and hallways—the places in which patients spend the majority of their time during their hospital stay. Falls are attributed to breakdowns in communication between patients and caregivers, inadequate assistance, and also the design of the physical environment.
Key Point Summary

Reducing Falls in a Definitive Observation Unit: An Evidence-Based Practice Institute Consortium Project

Author(s): Gutierrez, F., Smith, K.
A Definitive Observation Unit (DOU) in a hospital in California maintains high standards of nursing and follows an evidence-based practice of fall prevention. Yet the facility’s fall rates continue to be higher than the benchmark for similar hospitals.
Key Point Summary

One size fits all? Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience, safety and costs

Author(s): Maben, J., Griffiths, P., Penfold, C., Simon, M, Anderson, J. E., Robert, G., Pizzo, E., Hughes, J., Murrells, T., Barlow, J.
Authors indicate that despite the trend to adopt single-patient rooms, there is a dearth of strong evidence regarding its effect on healthcare quality and safety. When a hospital in England moved to a new building with 100% single rooms, a before-and-after move study was conducted on patient and staff experience, safety outcomes, and cost analysis. The study found that over two-thirds of the patients and one-fifth of the staff preferred single rooms.
Key Point Summary

Preventing falls in acute care: an innovative approach

Author(s): McCarter-Bayer, A., Bayer, F., Hall, K.