Annotated_Bibliography

Annotated Bibliography Garza, C.: Six Sigma and change management: Reducing hospital-acquired pressure ulcers. Patient Safety and Quality Healthcare, Apr. 2006. 
 This paper provides a description of using the Six Sigma process for reducing the incidence of hospital-acquired pressure ulcers in an urban hospital setting. After identifying that there was an unacceptably high incidence rate of pressure ulcers, a multidisciplinary team began a Six Sigma project with the goal of reducing pressure ulcer incidence, increasing patient satisfaction, reducing specialty bed rental and supply costs, and reducing length of stay associated with full-thickness pressure ulcers. Through data collection it was noted that monthly prevalence and incidence audits were important for improving staff confidence and promoting a foundation for changes in wound management. Upper level nursing management supported the process and interventions such as improving nurse-to-nurse communication and implementing daily interdisciplinary rounds in the ICU. Also, nurse-to-nurse discussion of the Braden score and skin status were initiated. Another initiative was improving nurse-to-physician communication. Hospital-acquired pressure ulcers decreased, and the costs associated with pressure-ulcers were reduced by $150,000. The author point's out, that Six Sigma process, allowed significant change in patient-care outcomes while decreasing costs. Kalisch B., Aebersold M. : Overcoming barriers to patient safety. Nursing Economic 24(3): 143–148, 155, 2006. 
 In this article the authors discuss common barriers to patient safety on a typical patient care unit in an acute care hospital. The article is an excellent and concise overview of the challenges faced in hospitals overall and on nursing units in particular. The authors address the importance of development of core values that promote excellence and respect, and they challenge the premise that punitive consequences can lead to improved outcomes. They cite results of a survey by the Institute for Safe Medication Practices of more than 1,500 nurses and noted that 93% of these nurses believed that they would suffer a restriction of licensure if they were involved in a fatal medication error. Another shocking statistic is that 88% of respondents reported some level of disrespectful response to questions or attempts to communicate concerns. The authors give a review of practical ideas that can promote safe practice, including creating value-driven units, reward systems for good practice and reporting of mistakes, simplifying the work, minimizing interruptions, commitment and promotion of teamwork. Freitag, M., Carroll, V. S. (2011). Handoff communication: using failure modes and effects analysis to improve the transition in care process. Quality Management in Health Care. The author discusses how handoff communication is a high-risk process that causes errors that lead to ineffective care delivery and patient safety breaches. A failure modes and effects analysis was utilized to proactively evaluate handoff through a risk priority scoring process that focused the improvement plan on communication from shift to shift and between units. The electronic medical record was utilized to standardize the handoff tool in SBAR (situation, background, assessment, and recommendation) format for both nurses and patient care technicians. Key concepts of Jean Watson's caring model were incorporated into workflow, along with team huddles, to hardwire team communication and patient-centered care. Changes to the handoff process were piloted on the telemetry unit then launched on remaining nursing units over time. Data targeting patient satisfaction and nurse-sensitive outcomes were collected pre and post-implementation with notable gains.