Nurses' Experience Implementing an Automated Video Monitoring System to Decrease the Risk of Patient Falls during a Global Pandemic.

Healthcare is a complex sociotechnical system where information systems (IS) and information technology (IT) intersect to solve problems experienced by patients and providers alike. One example of IS/IT in hospitals is the Ocuvera automated video monitoring system (AVMS), which has been implemented in more than 30 hospitals. The purpose of this study was to evaluate nurses' attitudes toward AVMS implementation over time as they received the training program developed for this intervention.

Quality Improvement Content in Physical Therapist Education: A Scoping Review.

Objective: The purpose of this study was to systematically review the literature regarding teaching quality improvement (QI) in physical therapist education based on the Institute of Medicine's 6-element definition of QI. Educational activities in QI methods in physical therapist professional education curricula, their developmental stage, and their level of evaluation were described.

Methods: Keywords related to physical therapist students and QI educational activities were used to search studies indexed in PubMed, CINAHL, and ERIC published from 2004 through November 2020.

Evaluation of Automated Video Monitoring to Decrease the Risk of Unattended Bed Exits in Small Rural Hospitals.

Objectives: This study aimed to evaluate the effectiveness of using 1 to 4 mobile or fixed automated video monitoring systems (AVMSs) to decrease the risk of unattended bed exits (UBEs) as antecedents to unassisted falls among patients at high risk for falls and fall-related injuries in 15 small rural hospitals.

Methods: We compared UBE rates and fall rates during baseline (5 months in which patient movement was recorded but nurses did not receive alerts) and intervention phases (2 months in which nurses received alerts). We determined lead time (seconds elapsed from the first alert because of patient movement until 3 seconds after an UBE) during baseline and positive predictive value and sensitivity during intervention.

Returning to life activities after hematopoietic cell transplantation in older adults.

Objectives: The prevalence of hematopoietic cell transplant (HCT) among older adults with hematological malignancies has more than doubled over the last decade and continues to grow. HCT is an intense process that can impact functional status and health-related quality of life. The objective of this paper is to describe the experience of returning to life activities after HCT in patients 60 years of age and older and the resources required to adapt and cope to limitations in physical, psychological, and cognitive function.

Patient and system factors associated with unassisted and injurious falls in hospitals: an observational study.

Background: Unassisted falls are more likely to result in injury than assisted falls. However, little is known about risk factors for falling unassisted. Furthermore, rural hospitals, which care for a high proportion of older adults, are underrepresented in research on hospital falls.

Group and Organizational Safety Norms Set the Stage for Good Post-Fall Huddles.

We explored group and organizational safety norms as antecedents to meeting leader behaviors and achievement of desired outcomes in a special after-action review case-a post-fall huddle. A longitudinal survey design was used to investigate the relationship between organizational/group safety norms, huddle leader behavior, and huddle meeting effectiveness. The sample included healthcare workers in critical access hospitals (N = 206) who completed a baseline safety norm assessment and an assessment of post-fall huddle experiences three to six months later.

The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project.

Background: Conducting post-fall huddles is considered an integral component of a fall-risk-reduction program. However, there is no evidence linking post-fall huddles to patient outcomes or perceptions of teamwork and safety culture. The purpose of this study is to determine associations between conducting post-fall huddles and repeat fall rates and between post-fall huddle participation and perceptions of teamwork and safety culture.

Evaluating the use of multiteam systems to manage the complexity of inpatient falls in rural hospitals.

Objective: To evaluate the implementation and outcomes of evidence-based fall-risk-reduction processes when those processes are implemented using a multiteam system (MTS) structure.

Data Sources/study Setting: Fall-risk-reduction process and outcome measures from 16 small rural hospitals participating in a research demonstration and dissemination study from August 2012 to July 2014. Previously, these hospitals lacked a fall-event reporting system to drive improvement.

Naturalistic Decision Making in After-Action Review Meetings: The Implementation of and Learning from Post-Fall Huddles.

The purpose of this study was to add to our understanding of Naturalistic Decision Making (NDM) in healthcare, and how After Action Reviews (AARs) can be utilized as a learning tool to reduce errors. The study focused on the implementation of a specific form of AAR, a post-fall huddle, to learn from errors and reduce patient falls. Utilizing 17 hospitals that participated in this effort, information was collected on 226 falls over a period of 16 months.

Shifting the paradigm: an assessment of the quality of fall risk reduction in Nebraska hospitals.

Purpose: To assess the prevalence of evidence-based fall risk reduction structures and processes in Nebraska hospitals; whether fall rates are associated with specific structures and processes; and whether fall risk reduction structures, processes, and outcomes vary by hospital type--Critical Access Hospital (CAH) versus non-CAH.

Methods: A cross-sectional survey of Nebraska's 83 general community hospitals, 78% of which are CAHs. We used a negative binomial rate model to estimate fall rates while adjusting for hospital volume (patient days) and the exact Pearson chi-square test to determine associations between hospital type and the structure and process of fall risk reduction.

A theory-driven, longitudinal evaluation of the impact of team training on safety culture in 24 hospitals.

Background: Effective teamwork facilitates collective learning, which is integral to safety culture. There are no rigorous evaluations of the impact of team training on the four components of safety culture-reporting, just, flexible and learning cultures. We evaluated the impact of a year-long team training programme on safety culture in 24 hospitals using two theoretical frameworks.

A cross-sectional assessment of stroke rehabilitation in Nebraska hospitals.

Objective: To assess the structure and process of stroke rehabilitation in Nebraska hospitals.

Design: Cross-sectional mail survey using the Dillman tailored-design method of administration.

Setting: Hospitals in Nebraska.

Prevalence, formation, maintenance, and evaluation of interdisciplinary student aging interest groups.

The authors describe the prevalence, formation, maintenance, and evaluation of student aging interest groups. They conducted a cross-sectional electronic survey of the 46 academic medical centers funded by the Donald W. Reynolds Foundation.

Nurse staffing in critical access hospitals: structural factors linked to quality care.

Evidence links the amount of registered nurse care to improved patient outcomes in large hospitals, but little is known about registered nurse staffing in small critical access hospitals, which comprise 30% of all US hospitals. Our study findings show that the unique work environment of critical access hospitals means registered nurses are often overextended, reassigned from inpatient care, and/or interrupted creating potential safety and quality risks. Further research is needed to understand what critical access hospitals consider "safe" levels of nurse staffing and what processes are implemented to mitigate these risks.

Errors prevented by and associated with bar-code medication administration systems.

As expected, bar-code medication administration systems can prevent medication errors. However, health care organizations must be aware of identified failure points in bar coding that may contribute to errors.

Translating research into practice: voluntary reporting of medication errors in critical access hospitals.

Context: Low service volume, insufficient information technology, and limited human resources are barriers to learning about and correcting system failures in small rural hospitals.

Purpose: This paper describes the implementation of and initial findings from a voluntary medication error reporting program developed by the Nebraska Center for Rural Health Research (NCRHR) to overcome these barriers in 6 Nebraska critical access hospitals (CAHs).

Methods: Participating Nebraska CAHs mailed copies of medication error reports to the NCRHR monthly for entry into a database.