Journal of nursing care quality
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Multicenter Study
An analysis of patient falls and fall prevention programs across academic medical centers.
UHC conducted an analysis of more than 25 000 patient fall reports entered into the UHC Patient Safety Net incident reporting tool. Gaps were found in the completion of fall risk assessments, the ability of tools to accurately assess risk, and prevention strategies in particular inpatient units and emergency department. Common factors in falls resulting in major harm or death included age more than 80 years, altered mental status, ambulation (often without assistance), toileting, and diuretics and anticoagulants.
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Delirium is an emerging topic in patient safety. However, in Korea, delirium is still underrecognized despite high incidence rates in Korean hospitals. We studied the impact of delirium on patient outcomes in Korean intensive care units (ICUs) and found that delirium is associated with higher in-hospital mortality, shorter survival over the course of hospitalization, longer ICU and hospital stays, more frequent readmission to the ICU for the same hospitalization event, and higher health care costs.
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Alarm fatigue desensitizes nurses to alarm signals and presents potential for patient harm. This project describes an innovative method of communicating cardiac monitor alarms to pagers using an alarm escalation algorithm. This innovation was tested on 2 surgical progressive care units over a 6-month period. There was a significant decrease in mean frequency and duration of high-priority monitor alarms and improvement in nurses' perception of alarm response time, using this method of alarm communication.