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Objective: To use population data to identify patient characteristics associated with a postpartum maternal emergency department visit within 90 days of discharge after birth.Methods: This retrospective cross-sectional study analyzed linked maternal discharge and emergency department data for all live California births from 2009 to 2011. The primary outcome was at least one emergency department visit within 90 days of hospital discharge after birth. Secondary outcomes included three or more visits within 90 days ("high utilization") and inpatient readmission. Independent variables included demographics (age, race or ethnicity, payer, income) and clinical characteristics (length of stay, antepartum complications, mode of delivery, and severe maternal morbidity at delivery). Multilevel logistic regression identified variables associated study outcomes; we validated the predictive model with a split-sample approach and receiver operating characteristic curve analysis.Results: Of 1,071,232 deliveries included, 88,674 women (8.3%) visited the emergency department at least once in the 90 days after delivery discharge. Emergency department use was significantly associated with Medicaid insurance (adjusted odds ratio [OR] 2.15, 95% CI 2.08-2.21), age younger than 20 years (adjusted OR 2.08, 95% CI 1.98-2.19), severe maternal morbidity at delivery (adjusted OR 1.58, 95% CI 1.49-1.71), antepartum complications (adjusted OR 1.46, 95% CI 1.42-1.50), and cesarean delivery (adjusted OR 1.40, 95% CI 1.37-1.44). Approximately one fifth of visits occurred within 4 days of discharge, and more than half were within 3 weeks. High utilizers comprised 0.5% of the entire sample (5,171 women) and only 1.2% of women presenting for emergency department care were readmitted. Receiver operating curve model analysis using the validation sample supported predictive accuracy for postpartum emergency department use (area under the curve=0.95).Conclusion: One in 12 California women visited the emergency department in the first 90 days after postpartum discharge. Women at increased risk for postpartum emergency department use per our validated model (eg, low income, birth complications) may benefit from earlier scheduled postpartum visits. [ABSTRACT FROM AUTHOR]

Purpose To present findings from the Collaborative Alliance for Nursing Outcomes' (CALNOC) hospital medication administration (MA) accuracy assessment in a sample of acute care hospitals. Aims were as follows: (1) to describe the CALNOC MA accuracy assessment, (2) to examine nurse adherence to six safe practices during MA, (3) to examine the prevalence of MA errors in adult acute care, and (4) to explore associations between safe practices and MA accuracy. Methods Using a cross-sectional design, point in time, and convenience sample, direct observation data were collected by 43 hospitals participating in CALNOC's benchmarking registry. Data included 33,425 doses from 333 observation studies on 157 adult acute care units. Results reveal that the most common MA safe practice deviations were distraction/interruption (22.89%), not explaining medication to patients (13.90%), and not checking two forms of ID (12.47%). The most common MA errors were drug not available (0.76%) and wrong dose (0.45%). The overall percentage of safe practice deviations per encounter was 11.40%, whereas the overall percentage of MA errors was 0.32%. Conclusions and Implications Findings predict that for 10,000 MA encounters, 27,630 safe practice deviations and 770 MA errors will occur. A 36% reduction in practice deviation per encounter prevents 4.4% MA errors. Ultimately, reliably performing safe practices improves MA accuracy. [ABSTRACT FROM AUTHOR]

Benchmarking is an indispensable tool as hospital leaders face challenges to balance efficiency with safe and effective care. Selection of appropriate 'like' hospitals is critical to the benchmarking aim of understanding comparative performance. Based on 10 years of observed outcome differences between small and large hospitals, the Collaborative Alliance for Nursing Outcomes (CALNOC) sought to empirically define small hospitals, and to determine if there were statistical differences between small and large hospitals for selected nursing sensitive outcome indicators. This article reports the examination of hospital size as a proxy characteristic to define 'like' hospitals for the purpose of benchmarking outcomes. Findings suggest that optimal classifications into small and large hospital size based on the outcome indicators of falls, falls with injury, and hospital-acquired pressure ulcers stage 2 or worse (HAPU 2+) were not consistent with historical administrative categories based on average daily census and not consistent by outcome. Statistical differences were only found with HAPU 2+ in critical care units, with no differences in the fall outcomes. These data did not support the use of size-based categories to define like hospitals for benchmark comparisons. [ABSTRACT FROM AUTHOR]

Objective: Predictive models for falls, injury falls, and restraint prevalence were explored within nursing unit structures and processes of care., Background: The patient care team is responsible for patient safety, and improving practice models may prevent injuries and improve patient safety., Methods: Using unit-level self-reported data from 215 hospitals, falls, injury falls, and restraint prevalence were modeled with significant covariates as predictors., Results: Fewer falls/injury falls were predicted by populations with fewer frail and at-risk patients, more unlicensed care hours, and prevention protocol implementation, but not staffing per se, restraint use, or RN expertise. Lower restraint use was predicted by fewer frail patients, shorter length of stay, more RN hours, more certified RNs, and implementation of fall prevention protocols., Conclusion: In the presence of risk, patient injuries and safety were improved by optimizing staffing skill mix and use of prevention protocols.

Objective: This study tested multivariate models exploring unit-level predictors of medication administration (MA) accuracy., Background: During MA, nurses are both the last line of defense from medication-related errors and a potential perpetrator of error. Direct observation reveals safe practices and the accuracy of medication delivery., Methods: Using a direct-observation, cross-sectional design, data submitted by 124 adult patient care units for 15600 medication doses, from January 2009 to April 2010, were studied., Results: Distractions and interruptions were the most common safe practice deviation. Characteristics of patient care units and RN hours of care affected nurses' safe practices and MA accuracy. Safe practices predict and mediate MA accuracy. A 5% decrease in safe practice deviations would reduce MA errors by 46% without any change in RN hours of care., Conclusion: Nurses' adherence to MA safe practices, combined with unit characteristics and staffing factors, has the potential to dramatically improve MA accuracy.

Objective: The objective of this study was to demonstrate the association between nurse staffing and adverse events at the shift level., Background: Despite a growing body of research linking nurse staffing and patient outcomes, the relationship of staffing to patient falls and medication errors remains equivocal, possibly due to dependence on aggregated data., Methods: Thirteen military hospitals participated in creating a longitudinal nursing outcomes database to monitor nurse staffing, patient falls and medication errors, and other outcomes. Unit types were analyzed separately to stratify patient and nurse staffing characteristics. Bayesian hierarchical logistic regression modeling was used to examine associations between staffing and adverse events., Results: RN skill mix, total nursing care hours, and experience, measured by a proxy variable, were associated with shift-level adverse events., Conclusions: Consideration must be given to nurse staffing and experience levels on every shift.

Objective: To describe effective methods to engage nurse leaders in structured interview research., Background: The American Organization of Nurse Executives has identified the support of nurse leader participation in research as a key strategy to achieving its education and research objectives, particularly with regard to identifying and documenting nursing sensitive outcomes. Previous studies have delineated several methods to increase participation., Methods: Nurse leaders of California labor and delivery units reporting more than 50 deliveries during 2002 were asked to participate in a structured interview about staffing and clinical policies on their unit. Recruitment methodology involved 3 levels of intervention, including introductory letters, follow-up contacts, and personal encouragement from senior regional leaders and nurse executives., Results: Of the 268 eligible hospitals, 225 (84%) participated in the study. Fifty-four percent (n = 114) of the structured interviews were scheduled upon initial and second contacts by the research coordinator, and 73% (n = 161) were completed at the first scheduled appointment. Unit managers or directors personally completed 91% (n = 205) of the interviews, with only 20 (8.9%) designated to a staff nurse., Conclusions: Nurse leader participation is essential to the success of research dependent on collecting information regarding nurse practices and clinical processes. Using a multilevel approach to engage nurse leaders in research, such as endorsements and "detailing" by opinion leaders, phone calls, electronic mail, and incentives, is an effective strategy.