Nurse staffing practices and adverse events in acute care hospitals: The research protocol of a multisite patient‐level longitudinal study

BackgroundRecent ecological studies have suggested that inadequate nurse staffing may contribute to the incidence of adverse events in acute care hospitals. However, longitudinal studies are needed to further examine these associations and to identify the staffing patterns that are of greatest risk. The aims of this study are to determine if (a) nurse staffing levels are associated with an increased risk of adverse events, (b) the risk of adverse events in relationship to nurse staffing levels is modified by the complexity of patient requirements, and (c) optimal nurse staffing levels can be established.Methods/designA dynamic cohort of all adult medical, surgical, and intensive care unit patients admitted between 2010 and 2015 to a Canadian academic health center will be followed during the inpatient and 7-day post-discharge period to assess the occurrence and frequency of adverse events in relationship to antecedent nurse staffing levels. Four potentially preventable adverse events will be measured: (a) hospital-acquired pneumonia, (b) ventilator-associated pneumonia, (c) venous thromboembolism, and (d) in-hospital fall. These events were selected for their high incidence, morbidity and mortality rates, and because they are hypothesized to be related to nurse staffing levels. Adverse events will be ascertained from electronic health record data using validated automated detection algorithms. Patient exposure to nurse staffing will be measured on every shift of the hospitalization using electronic payroll records. To examine the association between nurse staffing levels and the risk of adverse events, four Cox proportional hazards regression models will be used (one for each adverse event), while adjusting for patient characteristics and risk factors of adverse event occurrence. To determine if the association between nurse staffing levels and the occurrence of adverse events is modified by the complexity of patient requirements, interaction terms will be included in the regression models, and their significance assessed. To assess for the presence of optimal nurse staffing levels, flexible nonlinear spline functions will be fitted.DiscussionThis study will likely generate evidence-based information that will assist managers in making the most effective use of scarce nursing resources and in identifying staffing patterns that minimize the risk of adverse events.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-015-0278-1) contains supplementary material, which is available to authorized users.

Associations between nurse education and experience and the risk of mortality and adverse events in acute care hospitals: A systematic review of observational studies

Taking care of patients, relatives and staff after critical incidents and accidents

This update's findings for naldemedine and naloxone with oxycodone have been strengthened with two new trials, but conclusions have not changed. Moderate-certainty evidence for oral naldemedine on risk of spontaneous laxations and non-serious AEs suggests in people with cancer that naldemedine may improve bowel function over two weeks and increase the risk of AEs. There was low-certainty evidence on serious AEs. Moderate-certainty evidence for methylnaltrexone on spontaneous laxations over two weeks suggests subcutaneous methylnaltrexone may improve bowel function in people receiving palliative care, but certainty of evidence for AEs was low. More trials are needed, more evaluation of AEs, outcomes patients rate as important, and in children.

BackgroundSeveral review studies have shown that 3.4% to 16.6% of patients in acute care hospitals experience one or more adverse events. Adverse events (AEs) in hospitals constitute a significant problem with serious consequences and a challenge for public health. The occurrence of AEs in Portuguese hospitals has not yet been systematically studied. The main purpose of this study is to estimate the incidence, impact and preventability of adverse events in Portuguese hospitals. It is also our aim to examine the feasibility of applying to Portuguese acute hospitals the methodology of detecting AEs through record review, previously used in other countries.MethodsThis work is based on a retrospective cohort study and was carried out at three acute care hospitals in the Administrative Region of Lisbon. The identification of AEs and their impact was done using a two-stage structured retrospective medical records review based on the use of 18 screening criteria. A random sample of 1,669 medical records (representative of 47,783 hospital admissions) for the year 2009 was analyzed.ResultsThe main results found in this study were an incidence rate of 11.1% AEs, of which around 53.2% were considered preventable. The majority of AEs were associated with surgical procedures (27%), drug errors (18.3%) and hospital acquired infections (12.2%). Most AEs (61%) resulted in minimal or no physical impairment or disability, and 10.8% were associated with death. In 58.6% of the AEs’ cases, the length of stay was prolonged on average 10.7 days. Additional direct costs amounted to €470,380.00.ConclusionThe magnitude of these results was critical, reinforcing the need of more detailed studies in this area. The knowledge of the incidence and nature of AEs that occur in hospitals should be seen as a first step towards the improvement of quality and safety in health care.

Background: Patients with communication disability are at increased risk of experiencing an adverse event in hospital. Despite forming a particularly vulnerable patient group, little is known about the nature or cause of adverse events experienced by people with aphasia and their spouses in hospital. Aims: This study aimed to: (a) describe the adverse events experienced by people with aphasia and their spouses in hospital, (b) identify the situations, people, events, and outcomes relevant to the adverse events, and (c) identify commonalities in participant stories of adverse events. Methods & Procedures: In this narrative inquiry, ten people with chronic aphasia and their spouses participated in in-depth interviews about the adverse events they experienced or witnessed in hospital. A narrative analysis was used to discover common stories of adverse events and common content themes across the stories of experience. Outcomes & Results: Although a wide variety of adverse event types were identified in the participants' stories, “undesirable events” were among the most common, along with “inappropriate discharge home or inadequate discharge plan”. Reliance upon spouses during communicative interactions featured across the stories, with exclusion of spouses from important interactions on the ward representing a barrier to effective communication and a risk for adverse events. Participants suggested strategies for improving the safety of people with aphasia in hospital in the hope of preventing future adverse events in this population. Conclusions: Adverse events occurring in hospital were distressing to participants and often related to the presence of aphasia. Hospital policies should acknowledge the role that spouses have with patients with aphasia and ensure their inclusion to assist in prevention and management of adverse events in hospitalised patients with aphasia. The need for better discharge planning and information should also be recognised as a means of preventing adverse events.

The 2004 Canadian Adverse Events (AE) Study which focused on estimating the incidence of AEs in hospital settings found an annual AE rate of 7.5% of all hospital admissions in Canada (Baker et al. 2004). Although study findings in terms of patient outcomes are essential for hospitals to review their own practices, a thorough understanding of the contributing factors leading to adverse events will be an important next step for hospitals to correct the deficiencies that might act as barriers to providing safe patient care. In other words, a thorough investigation and analysis of structure and process factors within individual hospitals as they relate to patient outcomes is needed as a next step. In order to explore how structural and care-process factors might be linked to the occurrence of adverse events in hospitals, this article aims at building a predictive model, by using Donabedian's model of structure, process, outcome and analyzing secondary data of Ontario Registered Nurse Survey of Hospital Characteristics. Results revealed that perceived understaffing, inadequate support services, unpleasant work environment, poor teamwork and non-supportive administration impact negatively the number of tasks left undone by nurses, which in turn, influence negatively the occurrence and frequency of adverse events in hospitals. Results and implications are discussed.

To examine the association between nurses' reports of unmet nursing care needs and their reports of patients' receipt of the wrong medication or dose, nosocomial infections and patient falls with injury in hospitals. Because nursing activities are often difficult to measure, and data are typically not collected by health care organisations, there are few studies that have addressed the association between nursing activities and patient outcomes. Secondary analysis of cross-sectional data collected in 1999 from 10,184 staff nurses and 168 acute care hospitals in the US. Multivariate linear regression models estimated the effect of unmet nursing care needs on adverse events given the influence of patient factors and the care environment. The proportion of necessary nursing care left undone ranged from 26% for preparing patients and families for discharge to as high as 74% for developing or updating nursing care plans. A majority of nurses reported that patients received the wrong medication or dose, acquired nosocomial infections, or had a fall with injury infrequently. However, nurses who reported that these adverse events occurred frequently varied considerably [i.e. medication errors (15%), patient falls with injury (20%), nosocomial infection (31%)]. After adjusting for patient factors and the care environment, there remained a significant association between unmet nursing care needs and each adverse event. The findings suggest that attention to optimising patient care delivery could result in a reduction in the occurrence of adverse events in hospitals. The occurrence of adverse events may be mitigated when nurses complete care activities that require them to spend time with their patients. Hospitals should engage staff nurses in the creation of policies that influence human resources management to enhance their awareness of the care environment and patient care delivery.

As orthopaedic surgery moves toward bundled payments, there is growing interest in identifying patients at high risk of early postoperative adverse events. The purpose of this study was to develop and validate a risk-stratification system for the occurrence of early adverse events among patients treated with open reduction and internal fixation (ORIF) for a closed fracture of the ankle. Patients undergoing ORIF for a closed ankle fracture during the period of 2006 to 2017, as documented by the American College of Surgeons National Surgical Quality Improvement Program, were identified. For the 60% of patients randomly selected as the development cohort, multivariate Cox proportional hazards modeling was used to identify factors that were independently associated with the occurrence of adverse events (including events such as reoperation, surgical site infection, and pulmonary embolism). On the basis of these results, a nomogram analysis was used to generate a point-based risk-stratification system. To evaluate the validity of the point-based system, the system was applied to the remaining 40% of patients constituting the validation cohort and tested for its ability to predict adverse events. Of the 7,582 patients in the development cohort, 455 developed an adverse event (estimated adverse event risk of 6%). On the basis of Cox proportional-hazards regression, patients were assigned points for each of the following significant risk factors: +1 point for age of 40 to 59 years, +3 points for age of 60 to 79 years, +5 points for age of ≥80 years, +1 point for female sex, +2 points for chronic obstructive pulmonary disease (COPD), +2 points for insulin-dependent diabetes, +3 points for anemia, and +4 points for end-stage renal disease. The validation cohort included 5,263 patients. Among this second cohort, the risk-stratification system predicted the risk of early adverse events (p < 0.001; Harrell C = 0.697). The occurrence of early adverse events following ORIF for closed ankle fractures was associated with greater age, female sex, COPD, insulin-dependent diabetes, anemia, and end-stage renal disease. We present and validate a simple point-based risk-stratification system to predict the risk of early adverse events. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

This study aimed to determine whether patients in teaching hospitals are at higher risk of suffering from an adverse event during the summer trainee changeover period. We performed a retrospective analysis of data from the Medicare Patient Safety Monitoring System, a medical-record abstraction-based database in the United States. Hospital admissions from 2010 to 2017 for acute myocardial infarction, heart failure, pneumonia, or a major surgical procedure were studied. Admissions were divided into nonsurgical (acute myocardial infarction, heart failure, or pneumonia) and surgical. Adverse event rates in July/August were compared with the rest of the year. Hospitals were stratified into major teaching, minor teaching, or nonteaching. Results were adjusted for patient demographics, comorbidities, and hospital characteristics. Outcomes were the adjusted odds of having at least 1 adverse event in July/August versus the rest of the year. We included 185,652 hospital admissions. The adjusted odds ratios (ORs) of suffering from at least one adverse event in a major teaching hospital in July/August was 0.83 (95% confidence interval [CI], 0.69-0.98) for nonsurgical patients and 1.09 (95% CI, 0.84-1.40) for surgical patients. In minor teaching hospitals, the adjusted ORs were 0.96 (95% CI, 0.88-1.04) for nonsurgical patients and 0.99 (95% CI, 0.87-1.12) for surgical patients. In nonteaching hospitals, the adjusted ORs were 0.98 (95% CI, 0.91-1.06) for nonsurgical patients and 1.10 (95% CI, 0.96-1.24) for surgical patients. Patients admitted to teaching hospitals in July/August are not at increased risk of adverse events. These findings should reassure patients and medical educators that patients are not excessively endangered by admission to the hospital during these months.

Introduction: Patient safety and the occurrence of adverse events in hospitals is a topic which has been widely addressed over the last decades. In that respect, there has been an increasing interest in the effect of working conditions on patient safety, and whether understaffing and adverse events are correlated. This paper therefore reports results from a study of under- staffing of nurses understood as a lack of nurses available to conduct the tasks required of them. This implies that nurses are forced to ignore or postpone important tasks, thereby compromising patient safety. Purpose: The purpose of the study is to increase the knowledge of understaffing of hospital nurses, and the consequences that understaffing may have on patient safety. Methods: A literature search of the databases Chinal, Medline, Cochrane library, Isi Web of Science and Academic Search premiere was conducted in the period January 2014 to February, 2016. Results: Results are categorized into two main themes and four subthemes. The first main theme describes the direct relationship between understaffing and patient safety. Poor staffing increases the risk of mortality, and adverse conditions such as pressure ulcers, deep vein thrombosis and hospital-related infections. The second main theme relates to the indirect implications of understaffing for patient safety. These implications pertain to the lack of time that nurses could give each patient, limitations in the quality of nursing, and challenges in safe medication administration. Conclusions: The study documents the relationship between understaffing of nurses and adverse events in hospitals, revealingthat understaffing of nurses is a risk factor for hospitalized patients.

The assessment of adverse events in hospitals in Brazil

The objective of this study was to evaluate studies on the occurrence of adverse drug events (ADEs) in hospitals in order to learn about their frequency and characteristics, comparing the methods for identifying them and the various definitions. A search was conducted on MEDLINE and identified studies published from 2000 to 2009. Inclusion criteria were: studies in populations not selected for specific diseases or drugs and ADEs that occurred during hospitalization. Twenty-nine studies were selected, displaying multiple sources of heterogeneity, including differences in the study populations, surveillance techniques, definitions of ADEs, and indicators. The proportion of patients with ADEs ranged from 1.6% to 41.4% of inpatients and the rates ranged from 1.7 to 51.8 events/100 admissions. A considerable share of these events could have been avoided. The findings show that ADEs in inpatients are a public health problem. However, further studies are needed to monitor these adverse events in order to effectively promote safe drug use.

The occurrence of drug adverse events in hospital settings is high and generates cost excess. The purpose of the study was to identify drug-related events during hospital admissions and to estimate their prevalence. A retrospective study was carried out in the State of Rio de Janeiro, Southeastern Brazil. Hospitalizations from the Brazilian Health System's national hospital database during the period between 1999 and 2002 were assessed. Admitted cases including suspected drug adverse event cases with ICD-10 (2000) coding in the main diagnosis and/or secondary diagnosis fields were included in the study. Means and standard deviations of continuous variables as well as the statistical significance of differences were estimated using variance analysis (ANOVA with a 95% confidence interval). There were identified 3,421 drug-related adverse events, and a prevalence of 1.8 cases per 1,000 hospitalizations was estimated. Most cases occurred in males (64.5%) admitted in contracted (34.9%) and local public hospitals (23.1%) in the departments of psychiatry (51.4%) and internal medicine (45.2%), of them, 84.1% were discharged. Most of them were adverse drug reactions or drug poisoning, and there were significant difference (p<0.000) regarding age and length of stay between these categories. Patients having adverse events were younger (35.8 vs 40.5 years old) and stayed longer in hospital (26.5 vs 5.0 days). The frequency of drug adverse events, although lower than those findings of international studies, is significant. National hospital admission database was considered useful in the study of drug-related events.

This descriptive observational study analyzes adverse events in public hospitals in Hidalgo between 2013 and 2021. The main objective is to understand patient safety at the local level using data from the Adverse Event Recording System. Data from 1,830 surveys from 14 hospitals were collected, focusing on sociodemographic, clinical, and hospital service variables. The results indicate a higher prevalence of adverse events in women (59.78%) and in the age group of 21 to 30 years. The most common places of occurrence were Internal Medicine and Hospitalization, mainly during the morning shift. The most frequent incidents were medication-related, falls, and infections, with a majority classified as 'no harm'. Patient characteristics and the application of protocols were identified as factors most commonly present in adverse events. However, only 2.02% of the events underwent a root cause analysis. The study highlights the need to develop specific strategies for prevention and reporting, emphasizing continuous education of medical staff and the strengthening of hospital policies, and the consolidation of information on adverse events for future research.