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The prevention of medication administration errors (MAEs) represents a central focus of hospitals' quality improvement and risk management initiatives. Because the identification and reporting of MAEs is a nonautomated and voluntary process, it is essential to understand the extent to which errors may not be reported. This study reports the results of 2 multihospital surveys in which over 1300 staff nurses in each survey estimated the extent to which various types of nonintravenous (non-i.v.) and intravenous (i.v.)-related MAEs are actually being reported on their nursing units. Overall, respondents estimated that about 60% of MAEs are actually being reported. Considerable differences in estimated rates of MAE reporting were found between staff and supervisors working on the same patient care units. A simulation based on actual and perceived rates of MAE reporting is presented to estimate the range of errors not being reported. Implications regarding the reliability, validity, and completeness of MAEs actually being reported are discussed. [ABSTRACT FROM AUTHOR]

Background: Delivery of comprehensive care for persons with human immunodeficiency virus (HIV) infection in rural and low prevalence settings presents many challenges. We developed and evaluated a telehealth collaborative care (TCC) program for persons with HIV in a rural area., Objective: To determine the feasibility of TCC, and identify factors influencing implementation in rural settings., Design: Mixed methods evaluation of a quality improvement program with pre-measures and post-measures., Patients: Veterans with HIV infection in Iowa and Illinois., Intervention: TCC integrated HIV specialty care delivered by clinical video telehealth, with primary care delivered by generalist providers, in seven Community Based Outpatient Clinics (CBOCs) serving rural areas. Principles guiding TCC design were: 1) clear delineation of specialty and primary care clinic roles in co-managed care; 2) creation of processes to improve care coordination between specialty and primary care teams; and 3) use of a patient registry for population management across sites., Measures: Veterans Affairs (VA) healthcare system performance measures for care for HIV infection and common comorbidities, patient travel time to obtain care, and patient satisfaction. Qualitative evaluation involved semi-structured telephone interviews with patients., Key Results: Thirty of 32 eligible patients chose TCC over traveling to the HIV clinic for all care. Among 24 patients in TCC during the June 2011-May 2012 evaluation period, median age was 54 (range, 40-79), most (96 %) were men, and median CD4 count was 707 cells/cm(3) (range, 233-1307). VA performance measures were met for > 90 % of TCC patients. Median yearly travel time decreased from 320 min per patient prior to TCC to 170 min during TCC (p < 0.001). Interview themes included: 1) overcoming privacy concerns during care in local primary care clinics; 2) tradeoffs between access, continuity, and care coordination; and 3) the role of specialist involvement in collaborative care., Discussion: Telehealth Collaborative Care is a feasible approach to providing accessible and comprehensive care for persons with HIV in rural settings.

This study used data from the Delirium Among the Elderly in Rural Long-Term Care Facilities Study and data from the National Death Index (NDI) to examine mortality among 320 individuals. Individuals were grouped into noncases, subsyndromal cases, hypoactive delirium, hyperactive delirium, and mixed delirium on the basis of scoring using the Confusion Assessment Method (CAM), NEECHAM Scale, Mini-Mental State Examination (MMSE), Clinical Assessment of Confusion-A (CAC-A), and Vigilance A instruments. Risk ratios of mortality using "days of survival" did not reach statistical significance (α = .05) for any subgroup. Underlying cause of death (UCD) using International Classification of Disease, 10th version (ICD-10), showed typical UCD among older adults. There appeared to be clinical differences in UCD between delirium subgroups. Findings supported the conclusion that careful monitoring of patients with delirium and subsyndromal delirium is needed to avoid complications and injuries that could increase mortality.

To determine whether urine color, as measured by a color chart, might be a valid indicator of hydration status in frail nursing home residents, this study tested the associations between urine color and urine specific gravity. This is a descriptive correlational study set in seven nursing homes in eastern Iowa. Ninety-eight nursing home residents > or =65 years of age participated. Exclusion criteria for the study included: unstable congestive heart failure or diabetes, documented renal disease, hyponatremia (serum sodium <135 meq/L), terminal illness, acutely confused/delirious or urinary tract infection at baseline, and gastrostomy-tube dependence. Weekly urine specimens were collected. Ucol was measured first, using a urine color chart. Usg was determined using the Chemstrip Mini UA Urine Analyzer. Week-by-week Spearman rank order correlations between urine color and specific gravity for the total sample (n=98) ranged from r(s) = 0.3 - 0.7, p < .01; the PROC mixed model was significant, p < .01. In subgroup analyses (n=78), all females (r(s) = 0.67, p = .01) and both males (r(s) = 0.53, p = .01) and females (r(s) = 0.72, p =.01) with adequate renal function (Cockcroft-Gault estimated creatinine clearance [CrCl] values of > or =50 ml/min) had significant associations between average urine color and average Usg. Females with mild renal impairment (CrCl between 30 and 50 ml/min) also had significant associations between Ucol and Usg (r(s) = .64, p < .01). Ucol averaged over several individual readings offers another tool in assessing hydration status in Caucasian nursing home residents with adequate renal function measures by estimated CrCl values.

The purpose of this study was to evaluate whether lengthening the dwell time of peripheral i.v. catheters from 72 hours to 144 hours resulted in increased rates of phlebitis and/or infiltration. The study was conducted in medical/surgical units at a 110-bed teaching hospital with an i.v. team. Kaplan-Meier estimates of the success and failure and conditional failure probabilities were calculated for phlebitis and infiltration scores. Log rank tests were used to test for an association between the covariates and the time until failure. Drug irritation was the most significant predictor of phlebitis and infiltration rates in this study. The total difference in the estimated failure rates for the catheter lasting 6 days versus a new catheter inserted for another 3 days is 1.3%. Because the conditional failure probability estimates for days 4, 5, and 6 are slightly higher than for days 1, 2, and 3, consideration may be given to extending the dwell time of a peripheral i.v. catheter beyond 72 hours under certain circumstances.

This article describes a study of the costs of a pilot telemedicine chronic wound consultation clinic. Cost minimization analysis is the technique used to examine the costs of the clinic. The components of cost analysis include the fixed costs of personnel and equipment and the indirect costs of circuit and line charges. Cost avoidance is also examined. Cost avoidance evaluates what costs were avoided by the use of the telemedicine clinic. Additionally, the cost perspectives of the consulting agency, the referring agency, and the patient are examined. The average cost of a chronic wound consultation was $136.16 (acute care perspective). Costs of a traditional face-to-face consultation, if the residents were transported to the acute care facility would be $246.28. Fifteen telehealth consultations per month were used to determine per consultation costs for line charges and depreciation/maintenance costs. In this pilot study, a cost savings was realized and patients benefited. Increased volume will help to offset the cost of the equipment depreciation and maintenance and make telehealth chronic wound consultations more cost effective.

While acute confusion (AC) is frequently studied in the hospitalized elderly population, this phenomena has been largely ignored in elders who are residents in long-term care (LTC) facilities. The purpose of this study was to estimate the prevalence of AC in older LTC residents, the antecedent conditions present at the time of the AC event and the recognition rate of AC when assessed by staff nurses in two LTC facilities. This is a descriptive, longitudinal study with a 14 day follow-up period which incorporates a screening algorithm using AC instruments with established psychometric properties. A behavioral symptom instrument was also used in order to classify AC cases into clinical subtypes: hyperkinetic, hypokinetic and mixed. Staff nurses, using traditional assessment techniques and blinded to the case screening algorithm outcome, were asked to randomly evaluate both residents who were "clear" and those experiencing AC. Screening was conducted at both daytime and evening time-points. Of the 37 subjects followed. 15 (40.5%) screened positive for AC. Those AC cases with compromised cortical functioning indicative of Alzheimer's disease (n = 4) were particularly vulnerable to poor fluid intake. High risk medications (n = 7) and urinary tract infections (n = 7) were the most frequent antecedents. Most of the subjects experienced two or more antecedent conditions at the time of their AC. Staff nurses were able to identify 4 (26.7%) of the 15 instrument-positive residents, none of which were of a hypokinetic clinical subtype. These early results suggest a high prevalence of AC among elders in LTC, which may go unrecognized by bedside care providers.

Although nurses constitute the largest single group of healthcare providers in the United States, confusion exists about what nurses actually do. This article provides an overview of the Nursing Interventions Classification (NIC), which is the first comprehensive classification of nursing treatments. Quality management professionals will find the NIC useful in designing quality management programs, meeting Joint Commission standards, and planning redesign initiatives.