Cascade iatrogenesis: Factors leading to the development of adverse events in hospitalized older adults

International Journal of Nursing Studies

Volumn 46, Issue 11, 2009, Pages 1528-1535

  Thornlow, Deirdre K ^a,b   Anderson, Ruth ^a,b   Oddone, Eugene ^a,b,c  

^a DUKE UNIVERSITY SCHOOL OF MEDICINE   (United States)

^b DUKE UNIVERSITY   (United States)

^c Center for Health Services Research in Primary Care   (United States)

Author keywords

Adverse events; Cascade iatrogenesis; Complications; Nursing care; Postoperative respiratory failure

Indexed keywords

AGED; ARTICLE; HOSPITAL PATIENT; HOSPITALIZATION; HUMAN; IATROGENIC DISEASE;

AGED; HOSPITALIZATION; HUMANS; IATROGENIC DISEASE; INPATIENTS;

EID: 69949088901     PISSN: 00207489     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.ijnurstu.2009.06.015     Document Type: Article

References (74)

1. Agency for Healthcare Research and Quality, 2008. National Healthcare Quality Report. U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, Rockville, MD, February 2008, AHRQ Pub. No. 08-0040.
2. Aiken L., Clarke S., Sloane D., Sochalski J., and Silber J. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. The Journal of the American Medical Association 288 (2002) 1987-1993
3. Aiken L., Clarke S., Cheung R.B., and Sloane D.M. Educational levels of hospital nurses and surgical patient mortality. The Journal of the American Medical Association 290 12 (2003) 1617-1623
4. Amaravadi R.K., Dimick J.B., Pronovost P.J., and Lipsett P.A. ICU nurse-to-patient ratio is associated with complications and resource use after esophagectomy. Intensive Care Medicine 26 12 (2000) 1857-1862
5. Anderson R.A., Su H.F., Hsieh P.C., Allred C.A., Owensby S., and Joiner-Rogers G.L. Casemix adjustment in nursing systems research: the case of resident outcomes in nursing homes. Research in Nursing & Health 22 4 (1999) 271-283
6. Anderson, Issel, and McDaniel R. Nursing homes as complex adaptive systems: relationship between management practice and resident outcomes. Nursing Research 52 1 (2003) 12-21
7. Arozullah A.M., Daley J., Henderson W.G., and Khuri S.F. Multifactorial risk index for predicting postoperative respiratory failure in men after major noncardiac surgery. The National Veterans Administration Surgical Quality Improvement Program. Annals of Surgery 232 (2000) 242-253
8. Arozullah A.M., Khuri S.F., Henderson W.G., et al. Development and validation of a multifactorial risk index for predicting postoperative pneumonia after major noncardiac surgery. Annals of Internal Medicine 135 (2001) 847-857
9. Brennan T.A., Leape L.L., and Laird N. The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study I. The New England Journal of Medicine 324 (1991) 370-376
10. Brooks J.A. Postoperative nosocomial pneumonia: nurse sensitive interventions. AACN Clinical Issues 12 2 (2001) 305-323
11. Browning L., Denehy L., and Scholes R.L. The quantity of early upright mobilisation performed following upper abdominal surgery is low: an observational study. Australian Journal of Physiotherapy 53 1 (2007) 47-52
12. Callahan E.H., Thomas D.C., Goldhirsch S.L., and Leipzing R. Geriatric hospital medicine. The Medical Clinics of North America 86 (2002) 707-729
13. Cepeda M.S., Farrar J.T., Baumgarten M., Boston R., Carr D.B., and Strom B.L. Side effects of opioids during short-term administration: effect of age, gender, and race. Clinical Pharmacology and Therapeutics 74 2 (2003) 102-112
14. Cho S.H., Ketefian S., Barkauskas V.H., and Smith D.G. The effects of nurse staffing on adverse events, morbidity, mortality, and medical costs. Nursing Research 52 2 (2003) 71-79
15. Considine J. The role of nurses in preventing adverse events related to respiratory dysfunction: literature review. Journal of Advanced Nursing 49 6 (2005) 624-633
16. Dang D., Johantgen M.E., Pronovost P.J., Jenckes M.W., and Bass E.B. Postoperative complications: does intensive care unit staff nursing make a difference?. Heart & Lung 31 3 (2002) 219-228
17. Dimick J.B., Swoboda S.M., Pronovost P.J., and Lipsett P.A. Effect of nurse-to patient ratio in the intensive care unit on pulmonary complications and resource use after hepatectomy. American Journal of Critical Care 10 6 (2001) 376-382
18. Donabedian A. Evaluating the quality of medical care. Milbank Memorial Fund Quarterly 44 3 (Suppl. 1) (1966) 66-206
19. Duff B., Gardiner G., and Barnes M. The impact of surgical nursing ward nurses practicing respiratory assessment on positive patient outcomes. Australian Journal of Advanced Nursing 24 4 (2007) 52-56
20. Fanning M.F. Reducing postoperative pulmonary complications in cardiac surgery patients with the use of the best evidence. Journal of Nursing Care Quality 19 2 (2004) 95-99
21. Fong H.K., Sands L.P., and Leung J.M. The role of postoperative analgesia in delirium and cognitive decline in elderly patients: a systematic review. Anesthesia & Analgesia 102 4 (2006) 255-1266
22. Friese C.R., and Aiken L.H. Failure to rescue in the surgical oncology population: implications for nursing and quality improvement. Oncology Nursing Forum 35 5 (2008) 779-785
23. Gill T.M., Allore H.G., Holford T.R., et al. Hospitalization, restricted activity, and the development of disability among older persons. The Journal of the American Medical Association 292 17 (2004) 2115-2124
24. Hurst K. Relationships between patient dependency, nursing workload and quality. International Journal of Nursing Studies 42 (2005) 75-84
25. Inouye S.K., Studenski S., Tinetti M., and Kuchel G.A. Geriatric syndromes: clinical, research, and policy implications of a core geriatric concept. Journal of the American Geriatric Society 55 (2007) 780-791
26. Institute of Safe Medication Practices, 2002. ISMP medication safety alert! Pain Scales don't weigh every risk. Retrieved September 16, 2008 from http://www.ismp.org/newsletters/acutecare/articles/20020724.asp?ptr=y.
27. Joint Commission. 2009 Comprehensive Accreditation Manual for Hospitals (CAMH): The Official Handbook (2009), Joint Commission Resources, Inc., Chicago, IL
28. Kane R.L., Shamliyan T.A., Mueller C., Duval S., and Wilt T.J. The association of Registered Nurse staffing levels and patient outcomes: systematic review and meta-analysis. Medical Care 45 12 (2007) 1195-1204
29. Kovner C., and Gergen P.J. Nurse staffing levels and adverse events following surgery in U.S. hospitals. Image: Journal of Nursing Scholarship 30 4 (1998) 315-321
30. Kovner C., Jones C., Zhan C., Gergen P.J., and Basu J. Nurse staffing and postsurgical adverse events: an analysis of administrative data from a sample of U.S. hospitals, 1990-1996. Health Services & Research 37 3 (2002) 611-629
31. Kutney-Lee A., Lake E.T., and Aiken L.H. Development of the hospital nurse surveillance capacity profile. Research in Nursing & Health 32 April (2) (2009) 217-228
32. Lang T.A., Hodge M., Olson V., Romano P.S., and Kravitz R.L. Nurse-patient ratios: a systematic review on the effects of nurse staffing on patient, nurse employee, and hospital outcomes. Journal of Nursing Administration 34 7/8 (2004) 326-337
33. Leape L.L., Brennan T., Laird N., Hebert L., Localio R., Lawthers A., et al. The nature of adverse in hospitalized patients: results of the Harvard Medical Practice Study II. New England Journal of Medicine 324 (1991) 377-384
34. Lichting L.K., Knauf R., and Milholland D.K. Some impacts of nursing on acute care hospital outcomes. Journal of Nursing Administration 29 2 (1999) 25-33
35. Marcantonio E.R., Flacker J.M., Wright R.J., and Resnick N.M. Reducing delirium after hip fracture: a randomized trial. Journal of American Geriatric Society 49 (2001) 516-522
36. Mark B.A., Harless D.W., McCue M., and Xu Y. A longitudinal examination of hospital registered nurse staffing and quality of care. Health Services & Research 39 2 (2004) 279-300
37. Mayberry L.J., and Gennarro S. A quality of health outcomes model for guiding obstetrical practice. Journal of Nursing Scholarship 33 (2001) 141-146
38. McCaffery M., and Pasero C. Teaching patients to use a numerical pain-rating scale. American Journal of Nursing 99 12 (1999) 22
39. McCusker J., Kakuma R., and Abrahamowitcz M. Predictors of functional decline in hospitalized elderly patients: a systematic review. Journal of Gerontology 57A 9 (2002) M569-M577
40. McDaniel R.R., and Driebe D.J. Complexity science and health care management. In: Blair J.D., Fottler M.D., and Savage G.T. (Eds). Advances in Health Care Management vol. 2 (2001), JAI Press, Stamford, CT 11-36
41. McQuillan P., Pilkington S., Allan A., Taylor B., Short A., Morgan G., et al. Confidential inquiry into quality of care before admission to intensive care. British Medical Journal 316 7148 (1998) 1853-1858
42. Milisen K., Lemiengre J., Braes T., and Foreman M.D. Multicomponent intervention strategies for managing delirium in hospitalized older people: systematic review. Journal of Advanced Nursing 52 1 (2005) 79-90
43. Mitchell P., Ferketich S., and Jennings B. Quality health outcomes model: American Academy of Nursing Expert Panel on Quality Health Care. Journal of Nursing Scholarship 30 (1998) 43-46
44. Nakagawa M., Tanaka H., Tsukuma H., and Kishi Y. Relationship between the duration of the preoperative smoke-free period and the incidence of postoperative pulmonary complications after pulmonary surgery. Chest 120 3 (2001) 705-710
45. Needleman J., Buerhaus P., Mattke S., Stewart M., and Zelevinsky K. Nurse-staffing levels and the quality of care in hospitals. New England Journal of Medicine 346 (2002) 1715-1722
46. Overdyk F., Carter R., and Maddox R. New JCAHO pain standard bigger threat to patient safety than envisioned. Anesthesia and Analgesia 102 5 (2006) 1596
47. Picone D.M., Titler M.G., Dochterman J., Shever L., Kim T., Abramowitz P., et al. Predictors of medication errors among elderly hospitalized patients. American Journal of Medical Quality 23 2 (2008) 115-127
48. Pronovost P.J., Dang D., Dorman T., Lipsett P.A., Garrett E., Jenckes M., and Bass E.B. Intensive care unit nurse staffing and the risk for complications after abdominal aortic surgery. Effective Clinical Practice 4 5 (2001) 199-206
49. Prowse M. Postoperative pain in older people: a review of the literature. Journal of Clinical Nursing 16 1 (2007) 84-97
50. Qaseem A., Snow V., Fitterman N., Hornbake E.R., Lawrence V.A., Smetana G.W., et al. Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline from the American College of Physicians. Annals of Internal Medicine 144 8 (2006) 575-580
51. Radwin L., and Fawcett J. A conceptual model-based program of nursing research: retrospective and prospective applications. Journal of Advanced Nursing 40 (2002) 355-360
52. Rakel B., and Herr K. Assessment and treatment of postoperative pain in older adults. Journal of Perianesthesia Nursing 19 3 (2004) 194-208
53. Romano P.S., Geppert J.J., Davies S., Miller M.R., Elixhauser A., and McDonald K.M. A national profile of patient safety in US hospitals. Health Affairs 22 2 (2003) 154-165
54. Rothschild J.M., Bates D.W., and Leape L.L. Preventable medical injuries in older patients. Archives of Internal Medicine 160 October (2000) 2717-2728
55. Rothschild J.M., Hurley A.C., Landrigan C.P., Cronin J.W., Martell-Waldrop K., Foskett C., Burdick E., Czeisler C.A., and Bates D.W. Recovery from medical errors: the critical care nursing safety net. Joint Commission Journal of Quality and Patient Safety 32 2 (2006) 63-72
56. Shea R.A., Brooks J.A., Dayhoff N.E., and Keck J. Pain intensity and postoperative pulmonary complications among the elderly after abdominal surgery. Heart & Lung 31 (2002) 440-449
57. Silber J.H., Rosenbaum P.R., Schwartz J.S., Ross R.N., and Williams S.V. Evaluation of the complication rate as a measure of quality of care in coronary artery bypass graft surgery. Journal of the American Medical Association (JAMA) 274 4 (1995) 317-323
58. Silber J., Rosenbaum P., Trudeau M., Chen W., Zhang X., Kelz R., et al. Changes in prognosis after the first postoperative complication. Medical Care 43 2 (2005) 122-131
59. Sin M., Belza B., LoGerfo J., and Cunningham S. Evaluation of a community-based exercise program for elderly Korean immigrants. Public Health Nursing 22 5 (2005) 407-413
60. Smetana G.W. Preoperative pulmonary assessment of the older adult. Clinics in Geriatric Medicine 19 1 (2003) 35-55
61. Smetana G. preoperative pulmonary evaluation: identifying and reducing risks for pulmonary complications. Cleveland Clinic Journal of Medicine 73 S1 (2006) S36-S41
62. Smetana G., Lawrence V., and Cornell J. Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Annals of Internal Medicine 144 (2006) 581-595
63. Smith L.H. Opioid safety: is your patient at risk for respiratory depression. Clinical Journal of Oncology Nursing 11 2 (2007) 293-296
64. Soto R.G., Fu E.S., Vila Jr. H., and Miguel R.V. Capnography accurately detects apnea during monitored anesthesia care. Anesthesia and Analgesia 99 (2004) 379-382
65. Spilsbury K., and Meyer J. Defining the nursing contribution to patient outcome: lessons from a review of the literature examining nursing outcomes, skill mix and changing roles. Journal of Clinical Nursing 10 1 (2001) 3-14
66. Taylor S., Kirton O.C., Staff I., and Kozol R.A. Postoperative day one: a high risk period for respiratory events. American Journal of Surgery 190 5 (2005) 752-756
67. Thomas E.J., and Brennan T.A. Incidence and types of preventable adverse events in elderly patients: population based review of medical records. British Medical Journal 320 (2000) 741-744
68. Thornlow D. Increased risk for patient safety incidents in hospitalized older adults. Medsurg Nursing 13 6 (2009) in press
69. Titler M. Interventions related to surveillance. Nursing Clinics of North America 27 2 (1992) 495-502
70. Titler M., Dochterman J., Xie X.J., Kanak M., Fei Q., Picone D.M., et al. Nursing interventions and other factors associated with discharge disposition in older patients after hip fractures. Nursing Research 55 4 (2006) 231-242
71. Tsilimingras D., Rosen A.K., and Berlowitz D.R. Patient safety in geriatrics: a call for action. Journal of Gerontology 58A 9 (2003) 813-819
72. Unruh L. Licensed nurse staffing and adverse events in hospitals. Medical Care 41 1 (2003) 142-152
73. Unruh L. Nurse staffing and patient, nurse, and financial outcomes. The American Journal of Nursing 108 1 (2008) 62-71
74. Zeitz K., and McCutcheon H. Observations and vital signs: ritual or vital for the monitoring of postoperative patients?. Applied Nursing Research 19 (2006) 204-211