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Nursing and Patient Safety | AHRQ Patient Safety Network
Introduction The initial nursing assessment, the first step in the five steps of the nursing process, involves the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected. The nursing assessment includes gathering information concerning the patient's individual physiological, psychological, sociological, and spiritual needs.
It is the first step in the successful evaluation of a patient. Part of the assessment includes data collection by obtaining vital signs such as temperature, respiratory rate, heart rate, blood pressure, and pain level using an age or condition appropriate pain scale.
The assessment identifies current and future care needs of the patient by allowing the formation of a nursing diagnosis. The nurse recognizes normal and abnormal patient physiology and helps prioritize interventions and care. Admission history and physical assessment as soon as the patient arrives at the unit or status is changed to an inpatient Data collected should be entered on the Nursing Admission Assessment Sheet and may vary slightly depending on the facility Additional data collected should be added Documentation and signature either written or electronic by the nurse performing the assessment Summary Nursing Admission Assessment Documentation: Name, medical record number, age, date, time, probable medical diagnosis, chief complaint, the source of information two patient identifiers Past medical history: Prior hospitalizations and major illnesses and surgeries Assess pain: Location, severity, and use of a pain scale Allergies: Medications, foods, and environmental; nature of the reaction and seriousness; intolerances to medications; apply allergy band and confirm all prepopulated allergies in the electronic medical record EMR with the patient or caregiver Medications: Confirm accuracy of the list, names, and dosages of medications by reconciling all medications promptly using electronic data confirmation, if available, from local pharmacies; include supplements and over-the-counter medications Valuables: Record and send to appropriate safe storage or send home with family following any institutional policies on the secure management of patient belongings; provide and label denture cups Rights: Orient patient, caregivers, and family to location, rights, and responsibilities; goal of admission and discharge goal Activities: Check daily activity limits and need for mobility aids Falls: Assess Morse Fall Risk and initiate fall precautions as dictated by institutional policy Psychosocial: Evaluate need for a sitter or video monitoring, any signs of agitation, restlessness, hallucinations, depression, suicidal ideations, or substance abuse Nutritional: Appetite, changes in body weight, need for nutritional consultation based on body mass index BMI calculated from measured height and weight on admission Vital signs: Nurses' working conditions and patient safety The causal relationship between nurse-to-patient ratios and patient outcomes likely is accounted for by both increased workload and increased stress and risk of burnout for nurses.
Missed nursing care—a type of error of omission in which required care elements are not completed—is relatively common on inpatient wards. In one British studymissed nursing care episodes were strongly associated with a higher numbers of patients per nurse.
Burnout among clinicians both nurses and physicians has consistently been linked to patient safety risks, and some studies show that higher numbers of patients per nurse is correlated with increased risk of burnout among nurses.
The high-intensity nature of nurses' work means that nurses themselves are at risk of committing errors while providing routine care. Human factors engineering principles hold that when an individual is attempting a complex task, such as administering medications to a hospitalized patient, the work environment should be as conducive as possible for carrying out the task.
However, operational failures such as interruptions or equipment failures may interfere with nurses' ability to perform such tasks; several studies have shown that interruptions are virtually a routine part of nurses' jobs. These interruptions have been tied to an increased risk of errors, particularly medication administration errors.
While some interruptions are likely important for patient care, the link between interruptions and errors is one example of how deficiencies in the day-to-day work environment for nurses is directly linked to patient safety. Longer shifts and working overtime have also been linked to increased risk of error, including in one high-profile case where an error committed by a nurse working a double shift resulted in the nurse being criminally prosecuted.
Nurses who commit errors are at risk of becoming second victims of the error, a well-documented phenomenon that is associated with an increased risk of self-reported error and leaving the nursing profession. In their daily work, nurses are also frequently exposed to disruptive or unprofessional behavior by physicians and other health care personnel, and such exposure has been demonstrated to be a key factor in nursing burnout and in nurses leaving their job or the profession entirely.
Nursing and Patient Safety
All of these factors—the high-risk nature of the work, increased stress caused by workload and interruptions, and the risk of burnout due to involvement in errors or exposure to disruptive behavior—likely combine with unsafe conditions precipitated by low nurse-to-patient ratios to increase the risk of adverse events. Using a systems analysis perspective, active errors made by individual nurses likely combine with these aligned holes in the "Swiss Cheese Model of Medical Errors" to result in preventable harm.
Current context The National Quality Forum endorsed voluntary consensus standards for nursing-sensitive care in These included patient-centered outcomes considered to be markers of nursing care quality such as falls and pressure ulcers and system-related measures including nursing skill mix, nursing care hours, measures of the quality of the nursing practice environment which includes staffing ratiosand nursing turnover.
These measures are intended to illustrate both the quality of nursing care and the degree to which the working environment at an institution supports nurses in their patient safety efforts. The Magnet Hospital Recognition Program, administered by the American Nurses Credentialing Center a subsidiary of the American Nurses Associationseeks to recognize hospitals that deliver superior patient care and, partly on this basis, attract and retain high-quality nurses.
The program has its genesis in a study that sought to identify hospitals that retained nurses for longer than average periods of time.