Nurse's Role In Preventing Patient Harm

Nurse's Role In Preventing Patient From Hospital Harm or Iatrogenesis 

Iatrogenic or hospital related harms to patient. Nosocomial infections,drug reactions prevention strategies by nurses and health care organization.

What Is Iatrogenesis

    Latrogenesis is a common and serious hazard of hospitalization that is associated with increased patient morbidity and mortality, prolonged hospital stays, and nursing home placement, at significant cost to patients and health care organizations alike. From the Greek word iatro, iatrogenesis means harm brought forth by a healer or any unintended adverse patient outcome because of a health care intervention, not considered the natural course of the illness or injury. 

    Common well-known iatrogenic problems affecting older adults include adverse drug events (ADE), complications of diagnostic and therapeutic interventions, nosocomial or hospital-acquired infections (HAI), pain, and a variety of geriatric syndromes (eg, falls, delirium, functional decline, pressure ulcers). Less well recognized are the potentially harmful influences of the knowledge, values, beliefs, and attitudes of well-intentioned health care providers and patients themselves, upon patient outcomes. 

    The purpose of this chapter is to describe common iatrogenic problems affecting older adults and to describe the role of the nurse in preventing iatrogenic harm.latrogenesis is not new to modern medicine. In the 1840s, Semmelweis noted that deaths from puerperal sepsis were lower in those patients treated by midwives who were working only with laboring mothers (Hani, 2010). These low death rates contrasted sharply with high death rates in those mothers treated by medical students who were also dissecting cadavers and performing surgery. 

    Semmelweis introduced a hand-washing program that lowered the cases of fatal puerperal fever from 12.84% to 2.38%, leading to his development of germ theory and the critical role of hand hygiene in the prevention of infection. In 1981, Steel, Gertman , Crescenzi, and Anderson (2004) raised the alarm after reporting that, even with very conservative inclusion criteria, 36% of patients suffered at least one iatrogenic event during a hospital stay.

Statement of Problem

    Iatrogenesis became a commonly used term when medical errors causing patient harm made headlines with the release of the landmark Institute of Medicine (IOM; Kohn, Corrigan, & Donaldson, 1999) report, To Err is Human: Building a Safer Health Sys tem . It reported that errors made by medical practitioners caused between 44,000 and 98,000 deaths per year at a cost of up to $29 billion in unnecessary health care expenses, disability, and lost income. 

    The report strongly urged immediate, vast, and comprehensive systemwide changes, including both voluntary and mandatory reporting programs by health care organizations, jump-starting the patient safety movement of today. In 2004, a national study of 37 million Medicare patients in 5,000 hospitals found that an average of 195,000 people died every year because of potentially preventable patient safety incidents (Health Grades, Inc., 2004). Although To Err is Human called for cutting medical errors by half, iatrogenesis persists. 

    The Agency for Healthcare Research and Quality (AHRQ) reported to Congress in 2008 that preventable medical injuries were increasing by 19% annually (Agency for HealthCare Research and Quality. 2008). Further, in November 2010, the US Department and Health and Human Services' Office of the Inspector General reported an alarming increase in the number of deaths from adverse events-180,000 patients each year-associated with $4.4 billion to government costs. In addition, it is estimated that one in seven Medicare beneficiaries (13.5%) some 134,000 patients a month-experience at least one adverse event, many preventable (Wilson, 2010).

    The patients at greatest risk for experiencing an adverse event while in the hospital are alder (Rothschild, Bates, &Leape . 2000), critically ill ( Garrouste et al., 2008), or represent an ethnic or racial minority group (Johnstone &Kanitsaki , 2006), and up to 70% of the events are considered preventable ( Soop , Fryksmark , Köster , & Haglund, 2009; Zegers et al., 2009). The true extent of the problem remains poorly understood because of a host of factors. 

    Lack of standardization in the literature as to what constitutes iatrogenesis and different methods of data collection and analysis hinders knowledge of the issue. In addition, there is both a lack of recognition of the problem and standardized procedures for investigating and reporting adverse events by hospitals and providers, who are known to disagree about what constitutes a complication and quality of care ( Weingart et al., 2006 ) . 

    Patients themselves, especially older adults, are hesitant to formally identify and report iatrogenic harm, if they even recognize it. Many are too ill or do not understand sophisticated medical care enough to recognize an adverse event ( Bismark , Brennan, Paterson, Davis, &Studdert , 2006). As such, it is difficult to estimate the true human and financial cost of this problem, and what we know of iatrogenesis may be the tip of the iceberg

latrogenesis in the older adult

    The risk of an iatrogenic event is highest among patients 65 years and older (Rothschild et al., 2000; Rowell, Nghiem, Jorm , & Jackson, (2010), with evidence suggesting it affects between 10.6% and 58.3% of hospitalized older adults (Rowell et al., 2010; Steel et al., 2004; Marengoni et al., 2010: Thornlow , Anderson, &Oddone . 2009).A landmark Harvard Medical Practice Study in 2000 found that older adults suffered twice as many diagnostic complications , two-and-one-half times as many medication reactions, four times as many therapeutic mishaps, and nine times as many falls as compared to younger patients (Rothschild &Leape , 2000). 

    Utilization Project (HCUP) scores found that for 11 of 13 safety indicators, older patients, especially those older than 85 years, were more likely than younger patients to experience higher rates of adverse events ( Thornlow , 2009 ) . combination with either chronic renal failure or chronic obstructive pulmonary disease significantly increases the risk of adverse event-related, in-hospital death ( Marengoni et al., 2010). Patients admitted from a skilled nursing facility (SNF) are at a significantly greater risk for developing complications in the hospital (Malone &DantoNocton , 2004).

Endogenous risk factors for latrogenesis

    Normal age-related changes and diminished physiological reserve capacity, especially in hepatic, renal, and cognitive function, and impaired homeostatic and compensatory mechanisms impede the ability of the older patient to respond to the physiological and psychological stressors related to acute illness, and make the older adult more vulnerable to iatrogenesis. Age-associated physiological changes tend to exaggerate the effects of medications, leading to more adverse side effects, which are often treated with the addition of more medications, compounding the risk of iatrogenic harm. 

    This risk is potentiated by the presence of multiple comorbid conditions and drug-drug and drug-disease interactions from resulting polypharmacy (Robinson & Weitzel, 2008).Aging is associated with an increased risk of infection caused by immune senescence. This age-related blunting of the febrile response and the decreased physiological ability of many older adults to mount an immune response or a fever can delay diagnosis and treatment, and may result in inappropriate care (McElhaney, 2005). 

    A diminished thirst sensation dramatically increases the risk of dehydration in the older patient who, for functional or cognitive reasons, may also be unable to independently drink adequate amounts of fluids. The older adult with age-associated decline in cardiac reserve who is receiving continuous intravenous fluids is also at increased risk for iatrogenic congestive heart failure (CHF).

    Another important consideration is the atypical presentation of disease in the older adult. Early symptoms of acute medical conditions tend to be vague, more insidious, and atypical, and so are often missed or misinterpreted by clinicians, family, caregivers, and patients alike. This impairs accurate diagnosis and timely treatment, and subsequently results in a greater frequency of emergent, higher risk interventions. For example, an acute appendicitis in the older adult may present as nonlocalized abdominal discomfort or may not manifest symptoms until perforation occurs. 

    An older person with a myocardial infarction may have no pain at all. Older adults with a urinary tract infection (UTI) or pneumonia commonly present with confusion, falls, or functional impairment, rather than the typical symptoms of infection seen in younger persons . Lack of awareness of atypical presentation can lead to delay in treatment and to patients being inappropriately treated with high-risk medications or labeled as “demented.” rather than assessing for and treating unmet needs, such as delirium-related infection or pain. Exogenous risk factors for iatrogenesis.

    The hospital environment and the complex interrelationships of hospital and provider practice patterns influence patient safety outcomes. For example, inadequate nurse staffing has consistently been associated with adverse patient outcomes (Frith et al., 2010), and interruptions during clinical care are known to cause more nursing errors (Westbrook, Woods, Rob, Dunsmuir, & Day, 2010 ). 

    The hospital environment itself can also be hazardous to vulnerable elders with sensory, functional, and cognitive deficits, leading to more falls and fall-related injury. To further complicate matters, physicians and nurses are typically not adequately trained in geriatric care, and so are not prepared to manage the complex, chronic care needed by frail older patients (IOM, 2008). Without a solid understanding of the special needs of the geriatric patient and the factors within an organization that can increase risk, nurses may inadvertently cause more harm to patients during the course of treatment.

    The hospitalized older adult is at particularly high risk for cascade iatrogenesis, which occurs when an initial medical or nursing intervention triggers a series of complications, initiating a cascade of decline that is often irreversible (Robinson & Weitzel, 2008). For example, the cognitively impaired surgical patient who is inappropriately treated for pain may develop delirium, be medicated for agitated behaviors, become lethargic from oversedation, and subsequently develop aspiration pneumonia. 

    Deconditioning caused by prolonged bed rest increases fall risk and could lead to a fractured hip when the patient falls while trying to get to the bathroom. This prolongs the hospital stay, increasing the risk of further complications and adverse outcomes. Iatrogenic cascades have been found to occur most frequently among the oldest, most functionally impaired patients, and those with a higher severity of illness upon admission (Robinson & Weitzel, 2008).

Adverse drug events

    Adverse effects of medications are the most common type of iatrogenesis in hospitalized older adults. These include not only any adverse outcome that occurs during the course of routine, appropriate medication use, but also adverse outcomes caused by inappropriate prescribing, administration errors, and suboptimal adherence by the patient. It is estimated that 35% of older persons experience ADE every year, almost half of which are preventable (Safran et al., 2005). On average, patients with ADE experience longer hospital stays and have greater in hospital and 30-day mortality. 

    Some 10%-20% of older adults are prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) in spite of known gastrointestinal side effects, including ulcerations and bleeding, and the increased risk of impaired renal function, resulting in an estimated 3,300 excess deaths and 41,000 excess hospitalizations annually ( Arnstein , 2010). Still, many nurses and other health care practitioners are not aware of the risks, with some hospital protocols continuing to use NSAIDs as a first-line agent to treat pain in older adults, in spite of the 2009 guidelines from the American Geriatric Society (2009 ) to the contrary.

    Polypharmacy, which is prevalent among older patients, increases the risk of drug interactions, whose effect on this population is more dramatic. It has been shown to be a significant predictor of hospitalization, nursing home placement, death, hypoglycemia, fractures, impaired mobility, pneumonia, and malnutrition (Frazier, 2005). A 2004 national study estimated that 888,000 ADE occurred in hospitalized Medicare patients from high-risk medications alone, including warfarin, hypoglycemic agents, digoxin, and antibiotics (Classen, Jaser . & Budnitz , 2010 ) . 

    The nurse needs to closely monitor the patient for adverse side effects of medication and be aware of the need for age-adjusted doses especially with high-risk medications. Anticoagulation dosing based on creatinine clearance and weight, for example, is critical in order to avoid further harm to the patient (Jaffer &Brotman , 2006). Medication reconciliation upon admission, transfer, and discharge is another key strategy needed to maintain geriatric patient safety. The reader is referred to Chapter 17, Reducing Adverse Drug Events for assessment and interventions to prevent ADE.

Adverse Effects Of Diagnostic, Medical, Surgical, And Nursing Procedures

    Acutely ill older patients are at greatest risk for iatrogenic harm, due in part to the need for more diagnostic, prophylactic, and therapeutic medical, surgical, or nursing procedures and interventions.Diagnostic procedures involve some degree of risk based on whether they are invasive or administer a pharmacological or radiological agent, such as contrast material. Contrast dye, commonly used in CT scans and myelography, can produce both allergic and nonallergic reactions ranging from urticaria, angioedema, and anaphylaxis. 

    Radiocontrast infusion in patients with renal impairment can cause acute renal failure (ARF) or an exacerbation of CHF. Gadolinium, used as a contrast agent for magnetic resonance imaging (MRI), has been associated with nephrogenic systemic sclerosis in patients with impaired renal function. In addition, patients with preexisting renal impairment exposed to nephrotoxins such as aminoglycosides or a radiocontrast agent and patients with CHF given NSAIDs are at significantly greater risk for ARF (Cheung, Ponnusamy , & Anderton, 2008). 

    Exposure to iodinated radiocontrast material should be avoided or minimized in patients with renal insufficiency, and nursing staff must closely monitor the patient's hydration status before and after the use of contrast dye in diagnostic studies. Particular attention needs to be paid to the patient's orthostatic blood pressure, urine output, and jugular venous pressure (Cheung et al., 2008). Administering age-adjusted, appropriate medications to premedicate prior to procedures is critical, as is the ability of the nurse to question what may be a high-risk drug or dose for the older adult. For example, the anticholinergic antihistamine, diphenhydramine, which is routinely prescribed before a blood transfusion to prevent minor transfusion reactions, can precipitate delirium in older patients.

    Medical procedures such as thoracentesis and cardiac catheterization have also been linked to significantly more preventable adverse effects in the older adult, such as cardiac arrhythmias, bleeding, infection, and pneumothorax (Dumont, Keeling, Bourgu - gnon , Sarembock , &Turner , 2006 ) . 

    The literature is full of case reports of iatrogenic injuries and deaths due to medical or nursing procedures such as venous embolism caused by the injection of CT contrast (Imai, Tamada , Gyoten , Yamashita, &Kajihara , 2004); aspiration deaths caused by barium, emollient laxatives, and contrast medium (Hunsaker & Hunsaker, 2002); colonic perforations caused by endoscopy or enema ( Bobba &Arsura , 2004); and complications associated with percutaneous endoscopic gastrostomy tubes ( Ghevariya , Paleti , Momeni , Krishnaiah, & Anand, 2009). 

    Risk for injurious falls is higher in older adults with devices or lines that tether the patient to the bed. As such, proactive assessment of when to discontinue tethering devices, and ongoing evaluation of the potential safety hazard is important. Restraints, including full hospital bed rails, once a cornerstone of fall prevention programs, have increasingly been recognized as harmful and potentially fatal to patients. 

    It is the older adult who is at greatest risk for being restrained in an effort to prevent a fall or to manage agitated behaviors associated with delirium, so every effort must be made to implement nonpharmacological, restraint-free behavior management and fall prevention interventions as noted in the protocol chapters. Restraining the patient with physical devices or medication often exacerbates agitated behavior and may contribute to falls, aspiration, skin breakdown, deconditioning, and other complications, especially when applied without addressing pain, elimination, or other care needs.

     Medical and nursing interventions, even those that are considered relatively risk free, such as the administration of intravenous therapy, can be dangerous in the older patient. Excessive venipuncture (eg, from laboratory tests ordered daily in stable patients) places the vulnerable older patient at increased risk not only for infection, but also for phlebitis, venous thrombotic embolism (VTE), and unnecessary suffering. 

    Given the age-related reduced cardiac reserve, intravenous fluids can lead to preventable CHF or electrolyte abnormalities, Sherman (2005) identifies three forms of geriatric iatrogenesis, referred to as the hypos of hospitalization, that can delay discharge, increase costs, and lead to adverse patient outcomes. 

    Iatrogenic induced hypokalemia occurs when intravenous fluids are given without potassium, whereas orthostatic hypotension can be induced when an antihypertensive medication is given based exclusively on supine blood pressures. Transient decreases in oral intake in patients receiving oral hypoglycemic agents, or standing insulin orders can cause preventable hypoglycemia.

    Bed rest, in and of itself, can have serious negative effects on older patients, including functional decline, VTE, pressure ulcers, delirium, orthostatic hypotension, falls, anorexia, constipation, and fecal impaction, among other adverse outcomes. Older adults are at greatest risk for VTE, which is both preventable and common in hospitalized older adults, due in part to underuse of prophylactic anticoagulation (Jacobs, 2003). Aggressive pharmacological thromboprophylaxis is necessary unless there is a contraindication such as active bleeding, when mechanical prophylaxis with sequential compression devices is warranted (Jaffer &Brotman , 2006).

    Perioperative complications in older patients can be as high as twice that of younger patients, and mortality can be three to seven times higher (Saver, 2010). Bentrem , Cohen, Hynes, Ko, and Bilimoria (2009) found that older adults were more likely to experience the following surgical complications: cardiac (acute myocardial infarction and cardiac arrest), pulmonary (pneumonia, pulmonary embolism, and respiratory failure), and urological (UTI and renal failure). On a positive note, the authors found that surgical site infections (SSIs), postoperative bleeding events, VTE, and rates of return to the OR were not significantly different than those of younger adults.

     Nurses are called upon to take a more active role in identifying older patients at higher risk of surgical complications, given the evidence that only a small percentage of surgeons and anesthetists recognize these age-associated risks and routinely order commensurate postoperative monitoring in older patients ( Pirret , 2003). A simple preoperative nursing assessment tool used in more than 7,000 patients over a 2-year period identified the higher risk patients in need of improved postoperative monitoring and reduced acute admissions to the ICU from 40% to 19% ( Pirret , 2003 ) . 

    Saver (2010) recommends a multipronged approach to reduce surgical complications in the older adult that includes tracking clinical indicators, performing a thorough assessment protecting patients intraoperatively, and providing patient education. The assessment should review six preoperative markers that have been linked to 6-month mortality in older adults: impaired cognition, recent falls, low serum albumin, anemia, functional dependence, and multiple comorbidities. 

    Functional dependence in activities of daily living (ADLs) is the biggest predictor of mortality, and having four or more of the pre-operative markers predicted mortality with high sensitivity and specificity. Assessment findings can be used to target post-op interventions including prevention of delirium, falls, and functional decline. Also, nurses can collaborate with nutrition services to increase postoperative monitoring and management (Barbosa-Silva & Barros, 2005).

    Postoperative nursing care that focused on preventing infection, reducing tension at the surgical site, and optimizing nutritional status effectively prevents surgical wound dehiscence, a serious complication with up to 50% mortality ( Hahler , 2006). The older adult's oral intake needs to be carefully monitored and reported, and insulin adjusted to prevent hypoglycemia and optimize glycemic control (Sherman, 2005). 

    It is also important to monitor the geriatric patient for atrial fibrillation, a potentially preventable condition that occurs in about one-third of patients after coronary artery bypass surgery and has been associated with other complications, including cognitive changes, renal impairment, infection ( Mathew et al., 2004), and stroke (Lip & Edwards, 2006).

    Safe nursing processes of care must be adopted and well integrated into the hospital and nursing culture. Westbrook et al. (2010) demonstrated that interruption of a nurse during a medication pass resulted in a 12.1% increase in failure to follow a standard procedure and a 12.7% increase in clinical errors. Hospital initiatives now include efforts to ensure nurses who are passing medications are not disturbed and to expect more involvement by the patient in care decisions and treatment planning so as to mitigate this risk.

    Given the plethora of evidence that communication and other systems problems cause iatrogenic patient harm. The Joint Commission (TJC) mandates more involvement of patients in their care and formal time outs and other verification procedures at high-risk times to prevent wrong site surgeries and other errors. Prior to any invasive procedure, nurses must also ensure the patient clearly understands the inherent risks and benefits before giving informed consent. 

    Although health care professionals (HCPs) are trained to weigh the risks and benefits, it is critical to heighten one's assessment of the situation and to err on the side of caution in the geriatric patient. Potentially harmful diagnostic and therapeutic procedures may well be contraindicated if the potential benefit does not clearly increase the potential for improving patient outcomes. 

    This is particularly important, given the strong evidence that the older population tends to have lower rates of understanding the risks and benefits of the procedure for which they are providing written or verbal consent (Mahon, 2010), given the age-associated increase in sensory deficits, it is critical to identify and address any visual or hearing deficits that may impede patient understanding. Several discussions over time to evaluate and ensure that the patient understands the situation may be warranted. If a difference of professional opinion occurs, nurses are encouraged to bring significant issues of potential harm up the chain of command.

Hospital Acquired Infection

    HAI, first defined in 1970 by the Centers for Disease Control and Prevention (CDC) as one that develops in a patient after hospital admission, is a serious risk for any patient. Like other iatrogenic harm, the risk and potential for poor outcomes related to HAI arises dramatically with age (Duffy, 2002). HAIs are one of the leading causes of morbidity and mortality in hospitalized patients (World Health Organization (WHO), 2002). It is estimated that HAIs affect more than 2 million patients in the United States every year and cause at least 90,000 deaths ( Leape & Berwick, 2005), at a cost exceeding $4.5 billion ( Hollenbeak et al., 2006). 

    Although the true incidence is difficult to determine, evidence suggests that 5%-10% of patients develop HAI, which increases morbidity, mortality, length of stay, and cost of care ( Gordts , Vrijens , Hulstaert , Devriese , &Van de Sande , 2010; Lanini et al., 2009). In addition, a disturbing increase in risk has been noted in recent decades (Burke, 2003). The rate of HAI is highest among older (Rothschild et al., 2000) and critically ill patients, who tend to be the most sick and most immunocompromised, undergo more invasive procedures, and receive more intravascular devices, which significantly increases the risk of secondary infection.

    UTIs are the most common HAIs, accounting for 30% to 40% of all nosocomial infections ( Brosnahan , Jull, & Tracy, 2004). The risk is directly related to the use and duration of indwelling urethral catheters, accounting for approximately 80% of hospital-acquired UTIs. In one series, 99% of older patients who received an indwelling catheter developed a UTI during the acute hospital stay: 50% of catheters used were determined not to be clinically justified ( Hazelett , Tsai, Gareri , &Allen , 2006). 

    A systematic review of the effects of duration of indwelling catheters on patient outcomes revealed both a significant increase in UTIs when the catheter was left in for more than 48 hours and a reduction in hospital length of stay when it was removed within 48 hours (Fernandez & Griffiths, 2006). Even without a catheter, the older patient is at increased risk for a UTI because of age-related physiological changes, functional abnormalities (prostate enlargement), the use of medications that promote urinary retention, and chronic diseases that increase infection risk or impairment bladder function. 

    Catheter-Associated Urinary Tract Infection Prevention).Hospital-acquired pneumonia (HAP) is the second most common type of nosocomial infection after UTI, with an estimated mortality rate of 20%-46% ( Arozullah . Khuri , Henderson, Paley, & Daley, 2001), and is the third most Common postoperative complication after urinary tract and wound infections. Patients receiving continuous mechanical ventilation have a six- to twenty-one-fold increased risk of developing bacterial HAP (CDC, 2003). Pulmonary aspiration of secretions from the oropharyngeal or gastrointestinal tract is the most common cause of HAP and is considered preventable in the majority of cases (Weitzel, Robinson, & Holmes, 2006).

    Hospital-acquired bloodstream infections are common, serious, and costly infections that are a leading cause of death in this country (Wenzel & Edmond, 2001). These infections are most often related to the use of an invasive device, and more than 50% occur in the critically ill patient. Catheter-associated bloodstream infections (CABSI) are serious infections in ICU patients, occurring in 3%-7% of all patients with central venous catheters (Warren, Zack, Cox, Cohen, & Fraser, 2003), associated with increased mortality and cost (Shannon et al., 2006).

    SSI are the most common type of nosocomial infection in patients undergoing surgery, and are associated with prolonged and more costly hospitalizations (Malone. Genuit , Tracy, Gannon, & Napolitano, 2002). Patients with SSIs are also twice as likely to die, 60% more likely to be admitted to the ICU, and five times more likely to be hospitalized than patients who do not develop SSI (Kirkland, Briggs, Trivette, Wilkinson, & Sexton , 1999 ). 

    Gram-positive organisms account for the majority of bacterial infections (Malone et al., 2002). Although the risk of SSI varies according to type of surgery and patient specific factors, evidence demonstrates that factors related to the hospital itself, such as practice patterns and the environment of care, significantly increase the risk of patient harm ( Hollenbeak et al. , 2006 ).

    Other infections that commonly affect hospitalized older patients include those affecting the gastrointestinal tract, such as Clostridium difficile (C. difficile) colitis and the skin, such as methicillin-resistant Staphylococcus aureus (MRSA). C. difficile infections are affecting significant numbers of hospitalized older patients. It is estimated that 20%-40% of hospitalized patients are colonized with the C. difficile toxin as compared to 2%-3% of healthy adults (Bartlett, 2006). Fifteen percent to 25% of patients with antibiotic associated diarrhea, and more than 95% with pseudomembranous colitis carry the C. difficile toxin, which is becoming more refractory to treatment and more apt to relapse (Freeman et al., 2010; Dubberke et al ., 2010).

    The alarming increase in antimicrobial resistant organisms, such as MRSA and vancomycin resistant enterococcus (VRE) is of great concern. Patients older than 80 years of age are at significantly greater risk for being carriers of MRSA ( Eveillard , Mortier, et al., 2006). MRSA increased in prevalence from 2% of S. aureus infections in 1974 to 63% in 2004, whereas VRE has steadily increased from less than 1% in 1990 to 28.5% of enterococcal isolates in 2003 (CDC, 2006). 

    On a positive note, a more recent review from nine US hospitals suggests that MRSA decreased 9.4% per year from 2005 to 2008 (Kallen et al., 2010). Vancomycin resistance has been shown to be an independent risk factor for death and is associated with poor patient outcomes, including longer length of stay, increased mortality, and higher costs of care (Salgado & Farr, 2003). More recently, the increase in multiple drug resistant organisms has been associated with significantly longer hospital stays, increased costs, and higher mortality.

Interventions and Care Strategies
Nursing Strategies For Hospital-Acquired Infections

    Reducing the rate of HAI comprises one of TJC's National Patient Safety Goals and three of the six goals of the Institute of Healthcare Improvement (IHI) 5 Million Lives Campaign. The WHO and the CDC have published numerous guidelines for the prevention of health care infections with recommendations based on levels of evidence from the literature. Adherence to this evidence based best practices, such as hand hygiene and infection control, is key to preventing iatrogenic infections. The reader is referred to the list of evidence-based CDC guidelines at the end of this chapter.

    Infection control staff must be actively involved in implementing guidelines, training staff and performing ongoing surveillance, and reporting processes with support from hospital leadership. Infection control efforts need to address strict adherence to appropriate cleansing of equipment and the environment, isolation of colonized patients, and appropriate surveillance programs as outlined in CDC guidelines. 

    Hospitals participating in the CDC's National Nosocomial Infections Surveillance (NNIS) system significantly reduced bloodstream infections, UTIs, and pneumonia in ICU patients, as well as SSIs. Success was attributed to the use of standardized definitions and surveillance protocols and risk stratification for calculation of infection rates, combined with an active prevention program (Jarvis, 2003).

    Nurses play an important role in monitoring immunizations as well as antibiotic stewardship, critical to slowing the emergence of bacterial resistance. Nurses also have a voice in the formulation of policy as well as clinical decision making. They can educate other clinicians about a hospital's antibiotic prescribing policies, including reserving newer or broader-spectrum antibiotics and vancomycin for cases of proven drug resistance or life-threatening emergencies.

     Given the increased risk in patients who are mechanically ventilated, implementation of bundled evidence-based interventions for ventilator-associated pneumonia (VAP) prevention, such as those proposed by IHI, is imperative ( Wip & Napolitano, 2009). Avoidance of the supine position is critical in preventing aspiration pneumonia. especially in patients receiving enteral feeding (Li Bassi & Torres, 2011). Placing the patient in the prone position to promote drainage of oropharyngeal and airway secretions has also been noted to be beneficial, and more research is warranted in the use of the lateral Trendelenburg position (Li Bassi & Torres, 2011). 

    Although the evidence suggests that elevating the head of the bed between 30 and 45 degrees decreases the incidence of VAP adherence to the optimal 45-degree level is problematic and increases the risk of a sacral pressure ulcer. Unfortunately, there is limited evidence to recommend the safest, lowest head-of-bed (HOB) elevation (Li Bassi & Torres, 2011).

    Besides adherence to hand hygiene and HOB elevation, there is good evidence that routine oral care effectively reduces the rate of HAP in critical care patients (Simmons- Trau , Cenek , Counterman, Hockenbury , &Litwiller , 2004). Unfortunately, oral hygiene continues to be a nursing function of “low priority” in most health care settings (Wenzel & Edmond, 2001). A review of the evidence on subglottal secretion aspiration revealed it consistently and significantly reduced the incidence of VAP yet the practice is limited in clinical settings (Scherzer, 2010). 

    Systematic review of the factors associated with enteral feeding in preventing VAP found appropriate enteral feeding to be the most important factor (Chen, 2009). In addition, intermittent enteral feeding and ensuring small residual volume is recommended to reduce gastroesophageal reflux. and early feeding and increased total volume intake can prevent ICU mortality. 

    Use of an antiseptic oral rinse for cardiac-surgery patients, noninvasive positive pressure ventilation, condensate collection, subglottal secretion drainage, early extubating, and avoiding gastric overdistension and unplanned extubating have also been found to be effective preventive measures for VAP (Hsieh & Tuite, 2006).     

    Tolentino-Delos Reyes, Ruppert, and Shiao (2007) demonstrated a significant improvement in critical care nurses' knowledge and adherence to evidence-based practice after an educational program on the ventilator “bundle,” or set of interventions, to decrease VAP. The implementation of an evidence-based guideline in five US hospitals that included five nursing interventions (HOB elevation, oral care, ventilator tubing condensate removal, hand hygiene, and glove use) reduced the rates of VAP and length of ICU stay, although not significantly (Abbott, Dremsa , Stewart, Mark, & Swift, 2006).

    Central venous catheter infections can be significantly reduced using non-technological strategies such as strict hand washing, maximum sterile barrier precautions, use of antiseptic solutions, insertion and management by trained personnel, and continuing quality improvement programs (Gnass et al., 2004 ) . It has been suggested that cleansing the access port with either 70% alcohol or 3.15% chlorhexidine/70% alcohol for 15 seconds is effective in disinfecting the port ( Kaler & Chinn, 2007), and that nursing staff must be diligent in this practice protect the patient.

    Patients with malnutrition, diabetes, postoperative anemia, and ascites are known to be at increased risk for SSI, so nurses need to closely monitor those patients and collaborate with nutrition services to intervene as indicated (Malone et al., 2002). Multiple evidence-based guidelines for SSI prevention have been developed and include antibiotic prophylaxis within 1 hour of incision with discontinuation within 24 hours. As such, the timing of antibiotic administration must be a nursing priority, and attention paid to processes of care to ensure adherence (Gagliardi, Fenech, Eskicioglu , Nathens , & McLeod, 2009).

    Encouraging early mobilization and lung expansion interventions, such as coughing and deep breathing exercises, incentive spirometry, and chest physiotherapy, are critical nursing interventions to prevent atatelectesis , secretion retention, and pneumonia. Unfortunately, there is a clear lack of evidence in specifically which surgical patients most benefit from perioperative lung expansion interventions (Freitas, Soares, Cardoso, &Atallah , 2007; Lawrence, Cornell, & Smetana, 2006).

    Close monitoring and effective glycemic control in critically ill patients can effectively reduce nosocomial infection rates (Grey &Perdrizet . 2004), as well as in-hospital mortality and length of stay in the ICU ( Krinsley , 2004). Tight glycemic control of older adults, however, does not lower the risk of mortality in the inpatient setting and, in fact, can put seniors at risk for hypoglycemia and its complications ( Alagiakrishnan &Mereu , 2010).

     Besides active prevention measures, maintaining a high degree of vigilance for infection throughout the hospital stay is critical. Although assessment of vital signs and white blood cell counts provide important information, the more atypical presentation of infection requires that nursing staff closely monitor the geriatric patient for any cognitive and functional changes that could reflect the presence of infection. Nursing staff must be aware of the increased vulnerability of the frail, older patient due to immune senescence, which reduces the T cell response to an infectious agent. 

    Fever can be absent in 30%-50% of older adults with infection, and any two-point increase from baseline needs to be considered a fever equivalent. Infection may present as confusion if. decline in self-care ability, reduced food and/or fluid intake, re-emergence of previously resolved stroke symptoms, new incontinence, generalized asthenia, new-onset atrial fibrillation, worsened glycemic control, or a host of other subtle findings. The development of any of these conditions should prompt suspicion for occult infection. Thus, the role of the nurse as patient advocate is crucial one that demands ongoing vigilance.

Quality Improvement Initiatives to Minimize Infection

    Processes of care need to be reviewed and interdisciplinary quality improvement efforts initiated to minimize infection, as well as any patient harm. Gagliardi et al. (2009) found that individual knowledge, attitudes, and beliefs, along with systems issues, such as team communication, allocation of resources, and organizational support for promoting and monitoring care processes, highly influence practice regarding antibiotic prophylaxis for the prevention of SSI infection. They recommend written order sets, multidisciplinary pathways, and quality improvement strategies to ensure adherence to SSI prophylaxis.

    A 5-year nurse-led interdisciplinary patient safety initiative used a systems approach to improve nurse-identified issues by addressing human factors, staff education, and no blame reporting systems and successfully reduced the rate of serious ADEs by 45% (Luther et al. , 2002).     

    In addition, it effectively reduced (a) VAP (from 47.8 to 10.9/1000 ventilator days), (b) CABSI (from 90th to 50th percentile). (c) length of hospital stays (from 8.1 to 4.5 days), (d) RN vacancy rate, and (e) the use of contracted nurses by more than half (50% ICU, 65% medical-surgical units). Strong organizational commitment was noted as a key to success (Luther et al., 2002). Another study found monthly feedback of infection rates to staff and training resulted in a 66% reduction in CABSIs in the ICU (Coopersmith et al., 2002). 

    Providing nursing staff with quarterly unit-specific data on catheter-associated UTI rates reduced the overall rate of catheter patient days from 32 to 17.4/1000 at a cost savings of $403,000 for more than an 18-month period (Goetz, Kedzuf . Wagener, &Muder , 1999). Gastmeier et al. (2002) demonstrated that nosocomial infection rates can be reduced by quality improvement efforts such as quality circles and continuous surveillance. These findings demonstrate the importance of staff education and quality improvement efforts using a multidisciplinary approach and close interdepartmental collaboration and communication with organizational support at all levels.

Geriatric Syndroms

    Geriatric syndromes are health conditions associated with aging and frailty, with a variety of causes that fail to fall into discrete disease categories (Inouye, Studenski , Tinetti, &Kuchel , 2007). These syndromes are increasingly being recognized as serious and preventable iatrogenic complications that increase risk for adverse outcomes, including prolonged length of stay and discharge to a more dependent level of care, loss of function and independence, and even death ( Anpalahan & Gibson, 2008 ) . 

    They are highly prevalent, especially among the frail elders, multifactorial in nature, and associated with significant disability and diminished quality of life. Geriatric syndromes include, but are not limited to delirium, functional decline, falls, malnutrition, pressure ulcers, depression, incontinence, and pain that occur in the course of receiving medical and nursing care. The reader is referred to the appropriate book chapters in this book that address the assessment and management of these common iatrogenic geriatric syndromes.

    It has been suggested that geriatric syndromes need to be recognized as a valuable theoretical framework, and used to train nurses ( Stierle et al.,2006) and medical students (Olde Rikkert , Rigaud, van Hoeyweghen , & de Graaf, 2003). Tsilimingras , Rosen, and Berlowitz (2003) contend that the patient safety initiatives sparked by To Err Is Human do not go far enough to address the unique needs of the older patient who is at greatest risk for iatrogenic harm. 

    They recommend that geriatric syndromes need to be recognized as distinct iatrogenic events, going so far as to call them medical errors, and urge major system reform to address these preventable and costly problems. They propose the need to routinely identify and report all geriatric syndromes and, when they occur, proactively identify and address system failures, reduce ADEs, improve the continuity of care, improve geriatric training programs, and establish dedicated geriatric units ( Tsilimingras et al . , 2003).

Nursing Management of Geriatric Syndromes

    Evidence-based standards of practice for HAI. falls, functional decline, pressure ulcers, delirium, and other geriatric syndromes, as outlined in this book, need to be adopted in targeted high-risk patients to prevent iatrogenesis. Nurses are also encouraged to use risk assessment tools and best practice interventions, such as the ones described at the How to Try This series on the Hartford Center for Geriatric Nursing website (http://consultgerirn.org/resources). 

    Clinical pathways of evidence-based interventions designed to reduce complications in older adults have achieved measurable success in acute care hospitals. For example, a clinical pathway significantly reduced the postoperative morbidity in patients with hip fractures by reducing postoperative CHF and cardiac arrhythmias from 5% to 1%, and reducing postoperative delirium from 51% to 22% (Beaupre et al., 2006). In addition, nurses identifying the at-risk older adult and implementing delirium prevention best practice interventions is key to preventing this serious and costly complication (Fick,     

    Agostini, & Inouye, 2002). Vigilant nurses competent in geriatrics will use the knowledge of the concept of diminishing physiological reserve capacity to identify the need to balance diagnostic and therapeutic interventions with the need for rest and sleep. Closely monitoring sleep patterns in order to prevent sleep deprivation and scheduling tests and therapy only after the patient has adequate rest is critical to prevent delirium and promote healing.

    A nurse-driven mobility protocol has been shown to decrease functional decline and length of stay in hospitalized older adults ( Padula , Hughes, &Baumhover , 2009). Nurses also have a responsibility to optimize nutritional status in order to prevent iatrogenic complications. The older adult's oral intake needs to be carefully monitored and reported and insulin adjusted to prevent hypoglycemia and optimize glycemic control (Sherman, 2005).

     Nursing staff should routinely take orthostatic vital signs or at least measure the blood pressure of the older patient in the sitting position to ensure that significant orthostatic hypotension is not induced by treating supine hypertension (Sherman, 2005). Older adults tend to be at greatest risk for falling caused by a variety of intrinsic and extrinsic factors that are well documented in the literature. Proactive identification and management of risk factors is critical, and the reader is referred to Chapter 15, Fall Prevention: Assessment, Diagnoses, and Intervention Strategies.

    Pain, in and of itself, can be a form of iatrogenic harm. Pain management is a key nursing responsibility from an ethical, legal, and regulatory standpoint, and every effort must be implemented to ensure the patient is not suffering needlessly because of acute or chronic pain ( Pasero & McCaffery, 2001). 

    A 2010 study of older adults with pain on an acute medical unit found that (a) 70% of the patients had pain, although their nurses did not ask them if they had pain in 75% of these cases; (b) nurses documented pain assessment or management in only 33% of cases; (c) nearly 50% of patients did not receive a prescribed analgesic for their pain; (d) 14% of patients with pain did not have any analgesia ordered; and (e) more than 50% of the patients did not receive appropriate pain management (Coker et al., 2010).

    Undertreatment of pain in older adults may lead to the iatrogenic condition known as parudo addiction, where the HCP may confuse relief-seeking requests for more pain medication as the “drug-seeking behavior of an addict ( Pergolizzi et al., 2008). Under-treated pain limits function in older adults and has been shown to lead to disability and it can lead to decreased quality of life, depression, and diminished socialization (D'Arcy, 2009, Reid, Williams, & Gil, 2005). 

    Iatrogenic disturbance pain (IDP), the presence of day-to-day pain that accompanies routine nursing caregiving activities, has also been described as a significant source of suffering impacting quality of life (Mentes, Teer, & Cadogan, 2004). The reader is referred to Chapter 14, Pain Management for a more comprehensive discussion of this topic.

    In summary, nurses are in a unique role to prevent geriatric syndromes and cascade iatrogenesis (Robinson & Weitzel, 2008) and must use their knowledge of aging to proactively advocate for safe, quality geriatric patient care to members of the health care team. Moore and Duffy (2007) argue that the main reason why older adults are in the hospital is the need for nursing vigilance, whereby the nurse has the knowledge to understand what is happening, the ability to anticipate what can happen, to weigh the risks and benefits, and to intervene to minimize the risk and to monitor outcomes.

Interventions Related To Changing Provider And Patient Knowledge, Beliefs, And Attitudes

Nurses' Knowledge, Attitudes, and Beliefs

    Although the majority of the literature focuses on iatrogenic illness and injuries that result from either the commission or omission of a physical act, arguments can be made that equally detrimental effects to patients can occur as a direct result of the knowledge, values, attitudes, beliefs , fears, and biases of nurses and other HCPs. A nurse's perception of older adults as chronically ill and frail may foster increasing dependence and functional decline if the patient is not provided the opportunity or assistance to routinely ambulate or engage in self-care skills.

    A nurse who fails to place the patient's values ahead of his or her own may cause undue suffering and harm when these values are in conflict. Failure to treat pain in dying patients for fear of hastening death increases suffering, lowers quality of life remaining and conflicts with evidence that treatment of pain in dying patients can prolong life and provide a higher quality of the life that remains. 

    Conversely, nurses who participated in programs such as the End-of-Life Nursing Education Consortium (ELNEC) have reported an improvement in their knowledge, confidence, and attitudes regarding palliative care for dying patients as well as a decrease in their anxiety regarding death patients ( Barrere , Durkin, &LaCoursiere , 2008). Likewise, outdated myths and attitudes of aging can interfere with a nurse's role in protecting the vulnerable older adult, including effective pain management (D'Arcy, 2009). 

    It is well known that a significant number of nursing home patients suffer needlessly in pain due in part to fear of addiction that takes precedence over comfort. Older adults, more than any other age group, tend to be undertreated for pain (Robinson, 2007) and other conditions, including osteoporosis (Davis, Ashe, Guy, & Khan, 2006) and depression (Harman et al., 2002). The assumption that the quality of life of the demented person is “poor” may lead the nurse to assume that institutionalization or palliation is the most appropriate goal of care, regardless of the values of the elder (Kenny, 1990).

    Kenny (1990) asserts that the current and traditional system of hospital care not only perpetuates dependency and iatrogenesis among geriatric patients, but also “erodes” their identity, self-esteem, and individuality. In addition, prolonged hospital stays are known to increase social isolation, decrease function, and foster dependence (Graf, 2008). One is left to wonder how much this may contribute to the high rates of depression seen in the hospitalized older patient. 

    Nurses must be careful to distinguish between “care as discipline” and the gift of cane, defined by Fox as the relationship between the patient and the provider that is mediated by love, generosity, trust, and delight (Greenwood, 2007), The danger lies in labeling a recipient of care who has impaired cognition as a “dementia patient,” or a patient with multiple admissions as a “frequent flier,” thus diminishing sen - sitivity to the humanity of the individual who is hospitalized (Greenwood, 2007) . 

    A diagNosis of dementia may lead an uneducated or age-biased nurse to expect less of a patient, and inadvertently promote functional decline, or to inaccurately assess for pain and undermedicated, promoting patient suffering and more complications (D'Arcy, 2009). Nurses have a responsibility to educate themselves in order to act responsibly and safely. In addition, it is important to carefully examine one's values and beliefs systems, so as not to unwittingly contribute to the patient's suffering because of ignorance or biases against older patients that can compromise clinical objectivity and patient care.

Patient Knowledge, Attitudes, and Beliefs

    To make matters worse, older patients are known to underreport or deny symptoms (Coker et al., 2010), in part because they have grown accustomed to living with chronic aches and pains and may interpret new symptoms as the presentation of a long-standing health problems. They may believe the symptom is a normal part of aging or fear a loss of independence or worse institutionalization if they admit to a physical or cognitive deficit. Underreporting of pain is particularly common and problematic among older adults. 

    Some 40% of fatalities following hip replacement surgeries in seniors are caused by pulmonary embolism (Morrison et al., 2003). Researchers positive that this is related to immobility and could be because of seniors' reluctance to take needed pain medication that allows them to ambulate and participate in therapy, as well as providers lack of knowledge that severe pain is associated with a ninefold increased risk of delirium in cognitively intact patients (Morrison et al., 2003) means to prevent error and patient harm (Sherwood. Thomas, Bennett, & Lewis, 2002; Wallace, Spurgeon, Benn, Koutantji, & Vincent, 2009 ) .

Interventions Related To National And Organizational Priorities

    In 2010, the National Council of the State Boards of Nursing in the United States recognized the need to improve the educational preparation of nurses in geriatrics and. at the time of this publication, is in the planning stages to require all nurses to have training in the care of geriatric patients. In addition, the US Department of Health and Human Services (USDHHS, 2010) has included training in geriatric care by physicians, nurses, and other health care providers in its Healthy People 2020 goals. 

    These goals aim to increase the number of physicians and nurses certified in geriatric care from 2.7% to 3% for physicians and 1.4% to 1.5% for nurses-a 10% improvement for both disciplines.

    National geriatric nursing leaders have been promoting the geriatric nursing skills and competence of all nurses, including those in subspecialty nursing. Wakefield et al. (2005) argue that nursing and medical school must integrate patient safety principles into their curricula in order to teach HCPs to more effectively prevent and manage errors, and to ease the burden on an already overstretched health care system. More emphasis placed on teaching the “ aviation” model derived from high-risk industries, which emphasizes feedback, teamwork, and communication is recommended.

    The IOM's To Err Is Human report increased provider awareness to the dangers of diagnostic and therapeutic interventions and led to a significant increase in patient safety research, literature, and initiatives ( Stelfox , Palmisani , Scurlock, Orav , &Bates , 2006 ) . Continued funding for patient safety research and major patient safety initiatives such as those provided by the AHRQ, the IHI. Leapfrog Group, and the IOM will continue to support hospitals in their efforts to create safe care environments ( Leape & Berwick, 2005). Organizational imperatives to prevent latrogenesis.

    It is now well recognized that a significant proportion of iatrogenic complications are directly related to the complex interplay of organizational and human factors that create opportunities for patient harm ( Leape , 2009). Hospitals and nursing leadership are urged to comply with not only regulatory mandates, but also to embrace patient safety as an explicit organizational goal, actively promoting a just culture of safety in which everyone is aware of the significance of iatrogenesis. This goal is supported by practices that enforce, recognize, and reward safety behaviors at the individual, unit, and organizational levels (Dennison, 2005).

    Nurses at all levels play a pivotal role in promoting patient safety. They are not only the largest workforce of health care providers, providing the final safety checkpoint at the bedside (Hughes & Clancy, 2005). Ensuring nurse competence in geriatric nursing is critical to preventing iatrogenesis in vulnerable older patients, and hospitals that are committed to implementing geriatric best practices have been shown to positively influence patient care (Boltz et al., 2008). 

    Organizations that ensure coordinated and effective training in both patient safety and geriatric patient care, well integrated into staff orientation and ongoing training programs, are poised to be effective. Collaboration between nursing education and risk management, quality improvement, infection control, and medicine will help to identify an institution's educational priorities and the most appropriate training strategies.

    Although it is the lack of systems such as those for decision support and medication reconciliation that is often the cause of patient harm (Morris, 2004), hospitals have been known to assign culpability, punishment, and blame to individuals involved in the errors, rather than encourage the reporting of these errors to conduct a root cause analysis (Dennison, 2005; Morris, 2004). 

    Accordingly, a national survey of nurses in 25 US hospitals found that a large percentage of iatrogenic harm is not reported by nurses; a mere 36% felt near misses should be reported ( Blegen et al., 2004). Hospitals need to recognize both what constitutes high-risk situations and those patients most at risk of adverse outcomes, and implement effective patient safety and performance improvement strategies designed to minimize harm. Nursing peer review and other audit functions are important processes that promote the understanding of the factors involved in patient safety incidents (Diaz, 2008).

    Nurses need to be at the forefront and engaged in interdisciplinary efforts to improve the safety culture of an organization ( Blegen et al., 2010). Significant strides in improving patient care have been made with nurses actively involved in identifying care-related problems. For example, the IHI and the Robert Wood Johnson Foundation sponsored national initiative, Transforming Care at the Bedside (TCAB) creates, tests, and implements nurse-generated practice changes to improve patient care and safety ( Viney , Batcheller , Houston , &Belcik , 2006). 

    A nationwide study of the effect of nursing rounds at least every 2 hours, with specific attention to patient comfort, positioning, and toileting, demonstrated a significant decrease in call light use, and a subsequent reduction in patient falls and increase in patient satisfaction (Meade , Bursell , &Ketelsen , 2006). 

    A nurse-led project to improve medication administration reliability using strategies that addressed process improvement and nursing leadership skills led to a sustained accuracy rate of 96% at 18 months, from 85% at baseline ( Kliger . Blegen . Gootee , &O'Neil , 2009). The critical need for optimal implementation of, and adherence to, evidence-based practice, including adoption of nursing protocols, to minimize the risk of error and patient harm cannot be overemphasized.

Safety Promoting Structures and Processes

    Nursing leadership has the responsibility to ensure that hospital structure and processes of care maximize staff effectiveness and minimize the risk of harm for vulnerable patients. Safe patient care cannot be ensured without the appropriate organizational systems that promote a positive work environment and efficient communication of pertinent information.     

    Appropriate nurse staffing and nursing competence is imperative given strong evidence that both staffing levels and educational preparation inversely affect patient care and outcomes (Frith et al., 2010; Kendall-Gallagher &Blegen , 2010). The groundbreaking AHRQ report entitled Keeping Patient Safe: Transforming the Work Environment of Nurses demonstrated that staffing and workflow design clearly impact errors and patient safety outcomes (Page, 2004). 

    A study of HAIs in the ICU confirmed previous data that nurse staffing is directly related to infection rate. The authors noted an increase in infection several days after heavy workload and advocate maintaining staffing at higher levels to minimize the risk of infection ( Hugonnet , Chevrolet, &Pittet , 2007). Lower nurse staffing correlates with increased mortality (Aiken, Clarke, Sloane, Lake, & Cheney, 2008), and Loan, Jennings, Brosch, Depaul , and Hildreth (2003) call for the need to develop databases to further examine the effect on staffing data and patient outcomes. 

    Scott, Rogers, Hwang, & Zhang (2006) surveyed critical care nurses in the United States and found evidence that longer work hours not only decreased nurse's vigilance but also increased the risk of errors and near misses, supporting the IOM recommendations to limit nurse's work hours to a maximum of 12 hours in a 24-hour period. 

    Yet, in spite of increased attention and major research done in this area, lack of standardized data and other problems continue to prevent attempts to find a clear solution to the optimal staffing needed to minimize error ( Blegen , 2006). Research must continue in this area so that improvements in nurse staffing, work areas, and transfer of knowledge both between providers and within the organization is optimized in order to maintain patient safety ( Blegen , 2006).

    Communication and collaboration are vital to ensure appropriate exchange of information and coordination of care (IOM, 2001) because lack of communication is considered a major contributor to iatrogenic complications. TJC recognized that communication breakdown is the cause of nearly 70% of all sentinel events, whereas a study to elicit stories of preventable physical or psychological harm caused by medical error found breakdown in communication was a far greater problem than technical error (Kuzel et al . , 2004). 

    It is critical to evaluate and optimize what patient information is communicated during any hand-off report, especially at high-risk times, and create evidence-based guidelines as to what needs to be included during this process (Alvarado et al., 2006) . Inaccurate or absent information can dramatically increase the risk of harmful effects on older patients.   

    The plan of care for the older patient that lacks critical baseline functional and cognitive data can hamper recognition of subtle changes in condition and may contribute to functional decline and other adverse outcomes, including cascade iatrogenesis. Nurses need to include daily functional priorities and goals that have been developed with the patient and/or family into every shift or hand off report.

    Patient transfer or any hand off presents opportunities for increased harm to patients. Patient transfer from either another unit or hospital has been found to be independently associated with the development of nosocomial infections ( Eveillard , Quenon , Rufat , Mangeol , &Fauvelle , 2001 ), whereas patient transfer from hospital to a SNF is a significant risk factor for ADEs ( Boockvar et al., 2004). 

    Every effort must be made to also address the communication of appropriate data during any transfer of patient care. Posthospital medication management strategies using interdisciplinary teams, information technology, and transitional care models need to be considered to minimize the risk of ADEs post discharge (Foust, Naylor, Boling, &Cappuzzo , 2005). Phone calls to recently discharged patients can be an effective intervention to minimize adverse events and prevent unnecessary readmissions (Forster et al., 2004).

    Information technology has the potential to significantly improve our ability to provide safe patient care by enhancing communication and providing decision support. The electronic medical record (EMR) needs to be considered a priority by the organization as a means to ensure evidence-based patient care is implemented and monitored (IOM, 2001), yet a mere 1.5% of US hospitals have even basic EMR keeping in place, and only 9.1% have computerized physician order entry (CPOE; Landrigan et al., 2010).     

    A well-designed EMR with CPOE has been shown to reduce the number of medication errors by 81% (Koppel et al., 2005). Not only are prescription errors caused by illegible handwriting prevented, but also the EMR can ensure best-practice pre-scribing using standardized order sets and preprogrammed medication alerts to prevent adverse drug-drug interactions. The EMR also has the capability to provide decision support, promote continuity of care and decrease adverse events with more efficient communication among care providers, especially at high-risk times such as during cross-coverage (Petersen, Orav , Teich , O'Neil , & Brennan, 1998) and any hand off.     

    Computerized prompts to use a nonpharmacological sleep protocol, which is as effective and far less harmful than sedative-hypnotic medications and promotes higher quality sleep. has decreased the use of higher risk sleeping medications among hospitalized patients (Agostini, Zhang, & Inouye, 2007),

    Couple he al. (2005) warns, however, that attention needs to be paid to the role of the EMR in facilitating medication errors and every measure taken to reduce this risk after identifying 22 types of error risks with the CPOE system Limitations of CPOE and remain vigilant partners in care to ensure patient safety. It is also important that health care providers with geriatric expertise be involved from the onset with the building of the EMR to ensure that best-practice geriatric assessment and management protocols are included. 

    Environmental safety needs to be an organizational priority and should involve all staff and physicians. Routine safety rounds that include leadership and encourage open discussions of safety at the unit level can be successful in promoting a culture of safety ( Reinertsen & Johnson, 2010). Regularly scheduled safety inspections of the environment and equipment need to occur and include clinicians with geriatric expertise to assist in identifying potential safety hazards related to aging changes such as lighting and seating heights. 

    Standardization of equipment is important to minimize the risk of error, although mechanisms need to be in place to ensure prompt reporting and removal from service of any malfunctioning equipment. In addition, considering normal changes of aging is important when planning hospital construction and renovation, so that architectural design promotes geriatric patient safety and function.

Partnering With Patients

    Nurses can effectively encourage patients to be vigilant and proactive partners in care in order to prevent unnecessary harm (Hibbard, Peters, Slovic , &Tusler , 2005). Providing patient education about medical errors has been shown to increase self-advocacy behaviors and satisfaction in patients (Hibbard et al., 2005). Berntsen (2006) calls for the implementation of a patient-centered philosophy as a way of minimizing patient harm. Patient-centeredness expresses that the needs, wants, and preferences of the patient.