Failure to rescue in neonatal care

Journal of Perinatal and Neonatal Nursing

Volumn 25, Issue 3, 2011, Pages 275-282

  Gephart, Sheila M ^a   McGrath, Jacqueline M ^b   Effken, Judith A ^a  

^a UNIVERSITY OF ARIZONA   (United States)

^b VIRGINIA COMMONWEALTH UNIVERSITY   (United States)

Author keywords

failure to rescue; neonatal intensive care unit; nursing; nursing vigilance; patient safety

Indexed keywords

ARTICLE; HEALTH CARE QUALITY; HUMAN; LEGAL ASPECT; MALPRACTICE; NEWBORN; NEWBORN INTENSIVE CARE; NEWBORN NURSING; STANDARD; TOTAL QUALITY MANAGEMENT; TREATMENT FAILURE; UNITED STATES;

HUMANS; INFANT, NEWBORN; INTENSIVE CARE UNITS, NEONATAL; MALPRACTICE; NEONATAL NURSING; QUALITY IMPROVEMENT; STANDARD OF CARE; TREATMENT FAILURE; UNITED STATES;

EID: 80051721125     PISSN: 08932190     EISSN: None     Source Type: Journal    
DOI: 10.1097/JPN.0b013e318227cc03     Document Type: Article

References (44)

1. Beaulieu MJ. Failure to rescue as a process measure to evaluate fetal safety during labor. MCN Am J Matern Child Nurs. 2009;34(1):18-23.
2. Simpson KR. Failure to rescue: implications for evaluating quality of care during labor and birth. J Perinat Neonatal Nurs. 2005;19(1):24-34.
3. Silber JH, Romano PS, Rosen AK, Wang Y, Even-Shoshan O, Volpp KG. Failure-to-rescue: comparing definitions to measure quality of care. Med Care. 2007;45(10):918-925.
4. Unsafe staffing. Am J Nurs. 2003;103(7):13-14.
5. Clarke SP. Failure to rescue: lessons from missed opportunities in care. Nurs Inq. 2004;11(2):67-71. (Pubitemid 38758980)
6. Manojlovich M, Talsma A. Identifying nursing processes to reduce failure to rescue. J Nurs Adm. 2007;37(11):504-509.
7. Needleman J, Buerhaus PI. Failure-to-rescue: comparing definitions to measure quality of care. Med Care. 2007;45(10):913-915.
8. McDonald KM, Davies SM, Geppert J, Romano PS. Why rescue the administrative data version of the "failure to rescue" quality indicator. Med Care. 2007;45(4):277-279.
9. Reason J. Human error: models and management. West J Med. 2000;172(6):393-396.
10. Reason JT, Carthey J, de Leval MR. Diagnosing "vulnerable system syndrome": an essential prerequisite to effective risk management. Qual Health Care. 2001;10(suppl 2):ii21-ii25.
11. Reason J. Beyond the organisational accident: the need for "error wisdom" on the frontline. Qual Saf Health Care. 2004;13(suppl 2):ii28-ii33. (Pubitemid 39627120)
12. Reason J. Combating omission errors through task analysis and good reminders. Qual Saf Health Care. 2002;11(1):40-44. (Pubitemid 35265301)
13. Aiken LH, Clarke SP, Sloane DM, Lake ET, Cheney T. Effects of hospital care environment on patient mortality and nurse outcomes. J Nurs Adm. 2008;38(5):223-229.
14. Clarke SP, Aiken LH. Failure to rescue: needless deaths are prime examples of the need for more nurses at the bedside. Am J Nurs. 2003;103(1):42-47.
15. Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K. Nurse staffing and quality of care in hospitals in the United States. Pol Polit Nurs Pract. 2002;3(4):306-308.
16. Friese CR. Hospital nursing organization and outcomes for surgical oncology patients [dissertation]. Philadelphia, PA: University of Pennsylvania; 2005.
17. Friese CR, Aiken LH. Failure to rescue in the surgical oncology population: implications for nursing and quality improvement. Oncol Nurs Forum. 2008;35(5):779-785.
18. Lang TA, Hodge M, Olson V, Romano PS, Kravitz RL. Nursepatient ratios: a systematic review on the effects of nurse staffing on patient, nurse employee, and hospital outcomes. J Nurs Adm. 2004;34(7):326-337. (Pubitemid 39062609)
19. Seago JA, Williamson A, Atwood C. Longitudinal analyses of nurse staffing and patient outcomes: more about failure to rescue. J Nurs Adm. 2006;36(1):13-21.
20. Kane RL, Shamliyan TA, Mueller C, Duval S, Wilt TJ. The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis. Med Care. 2007;45(12):1195-1204.
21. Lee AK. The effect of the patient care environment on the outcomes of surgical patients with comorbid serious mental illness [dissertation]. Philadelphia, PA: University of Pennsylvania; 2007.
22. Sedman A, Harris JM II, Schulz K, et al. Relevance of the Agency for Healthcare Research and Quality patient safety indicators for children's hospitals. Pediatrics. 2005;115(1):135-145. (Pubitemid 43046292)
23. Snijders C, van Lingen RA, Klip H, Ftter WP, van der Schaaf TW, Molendijk HA, NEOSAFE Study Group. Specialty-based, voluntary incident reporting in neonatal intensive care: description of 4846 incident reports. Arch Dis Child Fetal Neonatal Ed. 2009;94:F210-F215. doi:10.1136/abc.2007.135020.
24. Simpson KR, Knox GE. Common areas of litigation related to care during labor and birth: recommendations to promote patient safety and decrease risk exposure. J Perinat Neonatal Nurs. 2003;17(2):110-125.
25. Meadow W, Bell A, Lantos J. Physicians' experience with allegations of medical malpractice in the neonatal intensive care unit. Pediatrics. 1997;99:e10. doi: 10.1542/peds.99.5.e10.
26. The Joint Commission. Sentinel Event Alert #30 Preventing infant death and injury during delivery. http://www.jointcommission.org/sentinel-event-alert- issue-30-preventing-infant-death-and-injury-during-delivery/. Accessed May 17, 2011.
27. Committee on Patient Safety and Quality Improvement. ACOG committee opinion. Number 367. June 2007. Communication strategies for patient handoffs. Obstet Gynecol. 2007;109(6):1503-1505.
28. Arora VM, Manjarrez E, Dressler DD, Basaviah P, Halasyamani L, Kripalani S. Hospitalist handoffs: a systematic review and task force recommendations. J Hosp Med. 2009;4(7):433-440.
29. Demopoulos D. Better info for handoffs. Hosp Health Netw. 2008;82(7):6-8.
30. Gray JE, Davis DA, Pursley DM, Smallcomb JE, Geva A, Chawla NV. Network analysis of team structure in the neonatal intensive care unit. Pediatrics. 2010;125(6): e1460-e1467.
31. Meyer GA, Lavin MA, Perry AG. Is it time for a new category of nursing diagnosis? Int J Nurs Terminol Classif. 2007;18(2):45-50.
32. Dean GE, Scott LD, Rogers AE. Infants at risk: when nurse fatigue jeopardizes quality care. Adv Neonatal Care. 2006;6(3):120-126. (Pubitemid 43795158)
33. Hamilton KE, Redshaw ME, Tarnow-Mordi W. Nurse staffing in relation to risk-adjusted mortality in neonatal care. Arch Dis Child Fetal Neonatal Ed. 2007;92: F99-F103. (Pubitemid 46423820)
34. Ebright PR, Urden L, Patterson E, Chalko B. Themes surrounding novice nurse near-miss and adverse event situations. J Nurs Adm. 2004;34(11):531-538. (Pubitemid 39491640)
35. Kattwinkel J, ed. Textbook of Neonatal Resuscitation, 6th Ed. Elk Grove Village, Il: American Academy of Pediatrics, American Heart Association; 2011.
36. Agency for Healthcare Research and Quality. TeamSTEPPS: national implementation. http://teamstepps.ahrq.gov/index. htm. Accessed May 17, 2011.
37. Clancy C, Tornberg D. TeamSTEPP: assuring optimal teamwork in clinical settings. Am J Med Qual. 2007;22:214-217.
38. Samra HA, McGrath JM, Rollins W. Patient safety in the NICU: a comprehensive review. J Perinat Neonatal Nurs. 2011;25(2):123-132.
39. ED Accreditation update. SBAR techniques help EDs comply with handoff regs. ED Manag. 2007;19(11, suppl):3-4.
40. Simons SL. Using CUS words in the NICU. Neonatal Netw. 2008;27(6):423-424.
41. Benson L, Mitchell C, Link M, Carlson G, Fisher J. Using an advanced practice nursing model for a rapid response team. Jt Comm J Qual Patient Saf. 2008;34(12):743-747.
42. Wynn JD, Engelke MK, Swanson M. The front line of patient safety: staff nurses and rapid response team calls. Qual Manag Health Care. 2009;18(1):40-47.
43. Van Voorhis K, Willis TS. Implementing a pediatric rapid response system to improve quality and patient safety. Pediatr Clin North Am. 2009;56(4):919-933.
44. Bender J, Shields R, Kennally K. Testing with simulation before a big move at Women & Infants Hospital. Med Health R I. 2010;93(5):145,149-150.