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Abstract
BACKGROUND The use of verbal orders has been identified as a potential contributor to poor quality and less safe care. As a result, many organisations have encouraged changing the verbal orders process and/or reducing/eliminating verbal orders altogether (Joint Commission (2005), Institute of Medicine (2001), Leapfrog organisation, Institute of Safe Medication Practices). Ironically there is a paucity of research evidence to support the widespread concern over verbal order. AIMS This paper describes the very limited existing research on verbal orders, presents a model of verbal order use identifying potential error trigger points and suggests a verbal order research agenda in order to better understand the nature and extent of the potential patient care safety threat posed by verbal orders.
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Affiliation(s)
- D S Wakefield
- Department of Health Management and Informatics, University of Missouri Center for Health Care Quality, Columbia, Missouri 65212, USA.
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2
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Wakefield DS, Brokel J, Ward MM, Schwichtenberg T, Groath D, Kolb M, Davis JW, Crandall D. An exploratory study measuring verbal order content and context. Qual Saf Health Care 2009; 18:169-73. [DOI: 10.1136/qshc.2008.029827] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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3
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Wakefield BJ, Blegen MA, Uden-Holman T, Vaughn T, Chrischilles E, Wakefield DS. Organizational culture, continuous quality improvement, and medication administration error reporting. Am J Med Qual 2001; 16:128-34. [PMID: 11477957 DOI: 10.1177/106286060101600404] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study explores the relationships among measures of nurses' perceptions of organizational culture, continuous quality improvement (CQI) implementation, and medication administration error (MAE) reporting. Hospital-based nurses were surveyed using measures of organizational culture and CQI implementation. These data were combined with previously collected data on perceptions of MAE reporting. A group-oriented culture had a significant positive correlation with CQI implementation, whereas hierarchical and rational culture types were negatively correlated with CQI implementation. Higher barriers to reporting MAE were associated with lower perceived reporting rates. A group-oriented culture and a greater extent of CQI implementation were positively (but not significantly) associated with the estimated overall percentage of MAEs reported. We conclude that health care organizations have implemented CQI programs, yet barriers remain relative to MAE reporting. There is a need to assess the reliability, validity, and completeness of key quality assessment and risk management data.
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Affiliation(s)
- B J Wakefield
- Iowa City VA Medical Center, 601 Hwy 6 W, Iowa City, IA 52246, USA.
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4
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Abstract
Pediatric cardiology consultation has been effectively delivered outside the tertiary care setting through the use of tele-echocardiography. This study examined the effectiveness of several tele-echocardiography connections and the satisfaction of the referring physicians using these services. Studies were transmitted via either a shared fiber-optic (DS3) connection (two sites), a dedicated fast-copper (ISDN-PRI) link, or by courier from a nearby (25-mile) or distant (170-mile) site. Time intervals between when echocardiograms were performed locally until they were received, interpreted, and reported were prospectively recorded. Referring physician satisfaction was assessed through a survey. The critical time between when a remote echocardiogram was performed and when its result was reported to the referring physician was primarily determined by the mode of transmission. The time interval between performing an echocardiogram and receiving the study was significantly longer for echocardiograms sent from the 170-mile courier site (2474 +/- 295 min) than either the 25-mile courier site (474 +/- 151 min), DS3 (374 +/- 121 min), or ISDN-PRI (129 +/- 16 min). Regardless of the method of transmission, all referring physicians felt that the service improved their ability to manage children, and they would recommend the service to their colleagues. Those using the courier service from the 25-mile away site were more concerned about the availability of a pediatric cardiologist and image quality, presumably due to the delay in response times. The time interval data provided in this study and the assessment of physician satisfaction provide important data as echocardiography laboratories implement tele-echocardiography services.
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Affiliation(s)
- A R Mehta
- Departments of Health Management and Policy, University of Iowa, Iowa City, Iowa, USA
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5
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Wakefield BJ, Wakefield DS, Uden-Holman T. Improving medication administration error reporting systems. Why do errors occur? Ambul Outreach 2000:16-20. [PMID: 11067442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Monitoring medication administration errors (MAE) is often included as part of the hospital's risk management program. While observation of actual medication administration is the most accurate way to identify errors, hospitals typically rely on voluntary incident reporting processes. Although incident reporting systems are more economical than other methods of error detection, incident reporting can also be a time-consuming process depending on the complexity or "user-friendliness" of the reporting system. Accurate incident reporting systems are also dependent on the ability of the practitioner to: 1) recognize an error has actually occurred; 2) believe the error is significant enough to warrant reporting; and 3) overcome the embarrassment of having committed a MAE and the fear of punishment for reporting a mistake (either one's own or another's mistake).
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Affiliation(s)
- B J Wakefield
- Iowa City VA Medical Center, and College of Nursing, at The University of Iowa, in Iowa City, IA, USA.
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6
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Wakefield DS, Tracy R, Einhellig J. Trends and implications of visiting medical consultant outpatient clinics in rural hospital communities. Hosp Health Serv Adm 1999; 42:49-66. [PMID: 10164898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
The emergence of visiting consultant clinics (VCC) represents an unstudied but potentially important mechanism for importing specialty physician services into rural areas. An analysis of five years of one state's VCC experience reveals a substantial increase in both availability and geographic accessibility. This study documents the market's response to the oversupply and hypercompetition among urban-based physician specialists. Patterns of VCC growth have varied markedly for different specialties.
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Affiliation(s)
- D S Wakefield
- Graduate Program in Hospital and Health Administration, University of Iowa, Iowa City 52242, USA
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7
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Abstract
OBJECTIVE To assess the level of consensus among the administrative and health care leaders at rural Iowa hospitals regarding service gaps and priorities for developing telemedicine services. METHODS In the summer of 1994, a survey was conducted of all rural hospital chief executive officers, chiefs of medical staffs, and directors of nursing in Iowa concerning their perceptions of telemedicine services. RESULTS With the exception of teleradiology, few clinical specialties received high ratings as areas of need or priorities for the development of telemedicine. There was a general lack of agreement among respondents from the same hospital on such priorities. In contrast, respondents expressed higher priorities for the development of telemedicine-based educational services. CONCLUSIONS The interest in teleradiology is consistent with the fact that teleradiology has been more thoroughly tested for medical efficacy than other telemedicine applications. Continuing medical education may represent another potential for widespread successful telemedicine application. Financial issues were reported as the greatest barriers to the development of telemedicine systems.
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Affiliation(s)
- D S Wakefield
- Office of the Vice President for Health Services, University of Iowa, Iowa City, USA
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8
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Abstract
Recent changes in the organization and delivery of physician services in rural areas suggest the need to update how physician availability is viewed and measured. The objective of this study was to empirically examine the effect of rural hospitals contracting with outside physicians for part or all of their emergency room coverage, and the use of urban specialists to staff outpatient clinics, on measures used to assess physician availability. Based on data from one rural state, the findings demonstrate the importance of adjusting for the importation of physician services into rural areas.
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Affiliation(s)
- D S Wakefield
- Graduate Program in Hospital and Health Administration, University of Iowa, Iowa City 52242, USA
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Booth BM, Ludke RL, Wakefield DS, Kern DC, du Mond CE. Relationship between inappropriate admissions and days of care: implications for utilization management. Hosp Health Serv Adm 1999; 36:421-37. [PMID: 10170796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
A critical issue for utilization management programs is how much of the hospitalization should be reviewed and whether information relative to the admission provides information about the subsequent days of stay. This study evaluates the relationship between the appropriateness (defined as overutilization of acute, inpatient services) of admissions and all days of stay in a probability sample of 6,063 hospitalizations from 50 Department of Veterans Affairs medical centers (VAMCs). Results suggest that preadmission reviews in hospital-based utilization management programs may eliminate not only unnecessary admissions but also, in most cases, completely inappropriate hospitalizations. In addition, except where inpatient-appropriate surgeries are not performed in a timely manner, review of the rest of the stay may not be an efficient use of time and resources.
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10
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Tracy R, Saltzman KL, Wakefield DS. Considerations in establishing visiting consultant clinics in rural hospital communities. Hosp Health Serv Adm 1999; 41:255-65. [PMID: 10157966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Establishing specialty clinics staffed by visiting medical consultants is one way that rural hospitals can increase local access to specialty care. This example of private sector-driven regionalization of health care services typically involves an agreement among urban specialists, rural hospitals, and local primary care physicians. The urban-based physicians provide limited on-site specialty services in the rural community for patients who are referred by local physicians or self-refer to the specialty clinics. The trend toward formalization of regional relationships across large geographic areas prompts both opportunity and need for careful consideration of visiting specialty clinic arrangements in rural hospital communities. This article delineates advantages and disadvantages associated with the development of Visiting Consulting Clinics (VCC) along with some ¿ground rules¿ to consider when establishing this type of service.
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Affiliation(s)
- R Tracy
- University of Iowa, Office of Community Based Programs, Iowa City 52242, USA
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11
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Abstract
Obtaining adequate physician availability remains a challenge to many rural communities. To ensure 24-hour emergency room physician coverage, many rural hospitals contracted for emergency room services from out-of-area and/or local physician. Survey findings for 99 rural and rural referral Iowa hospitals addressing the nature, extent, and cost of contracting physician coverage of the emergency room are presented. While nearly two-thirds of the hospitals reported contracting for at least some emergency room coverage, the extent and costs of contracts vary widely. Advantages and disadvantages of contracting for emergency room services are discussed.
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Affiliation(s)
- D S Wakefield
- College of Medicine and Graduate College, University of Iowa, Iowa City 52242
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12
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Zollo SA, Kienzle MG, Henshaw Z, Crist LG, Wakefield DS. Tele-education in a telemedicine environment: implications for rural health care and academic medical centers. J Med Syst 1999; 23:107-22. [PMID: 10435242 DOI: 10.1023/a:1020589219289] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Over 50 million people in the United States (about 20% of the population) live in rural areas, but only 9% of the nation's physicians practice in rural communities. It is difficult to recruit and retain rural health care practitioners, partly because of issues relating to professional isolation. New and enhanced telecommunications links between community and academic hospitals show promise for reducing this isolation and enhancing lifelong learning opportunities for rural health care providers. This paper will explore some of the issues involved in using interactive video (telemedicine) networks to transmit continuing medical education programming from an academic center to multiple rural hospitals. Data from a recent University of Iowa survey of the state's health educators will be presented as one approach to assessing the health care marketplace for the deployment of tele-education services.
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Affiliation(s)
- S A Zollo
- Telemedicine Resource Center, University of Iowa, Iowa City 52242, USA
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13
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Abstract
Because the identification and reporting of medication administration errors (MAE) is a nonautomated and voluntary process, it is important to understand potential barriers to MAE reporting. This paper describes and analyzes a survey instrument designed to assist in evaluating the relative importance of 15 different potential MAE-reporting barriers. Based on the responses of over 1300 nurses and a confirmatory LISREL analysis, the 15 potential barriers are combined into 4 subscales: Disagreement Over Error, Reporting Effort, Fear, and Administrative Response. The psychometric properties of this instrument and descriptive profiles are presented. Specific suggestions for enhancing MAE reporting are discussed.
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Affiliation(s)
- D S Wakefield
- Division of Health Management & Policy, University of Iowa, Iowa City 52242, USA.
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14
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Wakefield DS, Wakefield BJ, Borders T, Uden-Holman T, Blegen M, Vaughn T. Understanding and comparing differences in reported medication administration error rates. Am J Med Qual 1999; 14:73-80. [PMID: 10446668 DOI: 10.1177/106286069901400202] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The prevention of medication administration errors (MAEs) represents a central focus of hospitals' quality improvement and risk management initiatives. Because the identification and reporting of MAEs is a nonautomated and voluntary process, it is essential to understand the extent to which errors may not be reported. This study reports the results of 2 multihospital surveys in which over 1300 staff nurses in each survey estimated the extent to which various types of nonintravenous (non-i.v.) and intravenous (i.v.)-related MAEs are actually being reported on their nursing units. Overall, respondents estimated that about 60% of MAEs are actually being reported. Considerable differences in estimated rates of MAE reporting were found between staff and supervisors working on the same patient care units. A simulation based on actual and perceived rates of MAE reporting is presented to estimate the range of errors not being reported. Implications regarding the reliability, validity, and completeness of MAEs actually being reported are discussed.
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Affiliation(s)
- D S Wakefield
- Division of Health Management and Policy, College of Medicine, University of Iowa, Iowa City 52242, USA.
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D'Alessandro DM, D'Alessandro MP, Galvin JR, Kash JB, Wakefield DS, Erkonen WE. Barriers to rural physician use of a digital health sciences library. Bull Med Libr Assoc 1998; 86:583-93. [PMID: 9803304 PMCID: PMC226455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Rural physicians need access to quality medical information, but accessing information is difficult in rural settings. Digital health sciences libraries (DHSLs) offer the potential to make information more accessible to rural physicians. A telemedicine network was deployed to six rural hospitals in Iowa. Computers were installed allowing access to a DHSL and training sessions were held. The purpose of this study was to examine the barriers to use of a DHSL by rural physicians. METHODS Approximately one year after deployment of the telemedicine network, physicians were surveyed using a modified critical incident technique. RESULTS Seventy percent of the eligible physicians responded and 33% had used the DHSL. Primary barriers included insufficient training, being too time consuming to use, and distance of computers from physicians' practice sites. Non-DHSL users cited the difficulty of using the DHSL as their greatest barrier, while DHSL users cited the quality of the information resources. CONCLUSIONS This study identifies a number of barriers that exist to rural physicians use of a DHSL. Potential solutions to these barriers are discussed. DHSLs will finally reach their potential when they can be delivered by easy to use handheld computers seamlessly integrated into the rural physician's workflow.
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Affiliation(s)
- D M D'Alessandro
- Department of Pediatrics, University of Iowa College of Medicine, Iowa City 52242, USA.
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16
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D'Alessandro MP, D'Alessandro DM, Kash JB, Jurca DA, Wakefield DS, Schallau SJ, Galvin JR, Erkonen WE. A performance comparison of communication links between rural hospitals and a digital health sciences library. Bull Med Libr Assoc 1998; 86:564-8. [PMID: 9803301 PMCID: PMC226452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Rural physicians need access to digital health sciences libraries (DHSLs) that is easy and reasonably rapid. The goal of this project was to study rural hospitals' access to a DHSL on the Internet, by comparing differing access speeds with differing costs and their acceptability for retrieving text, image, and video information in a DHSL. METHODS DHSL system response time was measured at three different times during the day over three different types of network connections (T1, Frame Relay, Modem). Text, image, and video information was retrieved. Costs were determined for installation and operation of the different types of network connections. RESULTS System response times were consistent at the three different testing times for each media type retrieved by each of the three network connection types. System response times for text retrieval met literature standards for all connections. Image retrieval met literature standards for T1 and Frame relay connections. No connection met literature standards for video retrieval. CONCLUSIONS High speed access to DHSLs is preferable; Frame relay connections provide substantively similar service as T1 connections at less cost. However, access via modem to a DHSL can provide access to the majority of information--text--in a DHSL with an acceptable system response time.
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Affiliation(s)
- M P D'Alessandro
- Department of Radiology, University of Iowa, College of Medicine, Iowa City 52242, USA.
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Hendryx MS, Fieselmann JF, Bock MJ, Wakefield DS, Helms CM, Bentler SE. Outreach education to improve quality of rural ICU care. Results of a randomized trial. Am J Respir Crit Care Med 1998; 158:418-23. [PMID: 9700115 DOI: 10.1164/ajrccm.158.2.9608068] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study tests whether an outreach educational program tailored to institutional specific patient care practices would improve the quality of care delivered to mechanically ventilated intensive care unit (ICU) patients in rural hospitals. The study was conducted as a randomized control trial using 20 rural Iowa hospitals as the unit of analysis. Twelve randomly selected hospitals received an outreach educational program. After review of the medical records of eligible patients, a multidisciplinary team of intensive care unit specialists from an academic medical center delivered an educational program with content specific to the findings and capacity of the hospital. The outcome measures included patient care processes, patient morbidity and mortality outcomes, and resource use. Results indicated that the outreach program significantly improved many patient care processes (lab work, nursing, dietary management, ventilator management, ventilator weaning). The program marginally reduced hospital ventilator days. Both total length of stay and ICU length of stay fell markedly in the intervention group (by an average of 3.2 and 2.1 d, respectively), while the control group fell only 0.6 and 0.3 d, respectively. However, these effects did not reach statistical significance. Unfortunately, the program had no detectable effects on the clinical outcomes of mortality or nosocomial events. We conclude that an outreach program of this type can effectively improve processes of care in rural ICUs. However, improving processes of care may not always translate into improvement of specific outcomes.
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Affiliation(s)
- M S Hendryx
- Health Policy and Administration, Washington State University, Spokane, Washington, USA
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18
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Wakefield BJ, Wakefield DS, Uden-Holman T, Blegen MA. Nurses' perceptions of why medication administration errors occur. Medsurg Nurs 1998; 7:39-44. [PMID: 9544009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Nurses play a key role in medication administration in hospital settings. Five categories of reasons for medication errors were identified in a survey of 1,384 nurses. These categories include physician, systems, pharmacy, individual, and knowledge-related factors. In this article, issues surrounding the occurrence and prevention of medication errors are discussed.
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Affiliation(s)
- B J Wakefield
- Department of Veteran's Affairs Medical Center, Iowa City, IA, USA
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19
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Abstract
This article examines the applicability of a "report card" strategy as a means of differentiating among providers on the basis of performance. The specific focus is on the potential effect of differences in data collection processes on the meaningfulness of subsequent comparisons among similar types of providers. Variations in reported nosocomial infection rates are analyzed in light of differences in reported surveillance practices; data for similar nursing units are analyzed as well. Thirty-one rural, rural referral, and urban acute care hospitals in the midwest participated in the study. The reported nosocomial infection rates for different types of nursing units and different hospital groups varied substantially. Likewise, there were marked variations in the nosocomial infection surveillance practices at the hospitals, which were found to explain some of the variation in the reported nosocomial infection rates for specific types of nursing units and nosocomial infections. The study conclude that differences in data collection processes may result in incorrect conclusions about differences in the quality of care provided by various providers.
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20
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Wakefield DS, Wakefield BJ, Uden-Holman T, Blegen MA. Perceived barriers in reporting medication administration errors. Best Pract Benchmarking Healthc 1996; 1:191-7. [PMID: 9192569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Assuring that medication administration error (MAE) reports are reliable and valid is of great significance for the patient, the hospital, and the nurse. In most hospitals, MAE reporting relies on the nurse who discovers an error to initiate an error report, whether the error was committed by that nurse or someone else. Because of the potential for negative consequences, there may be significant disincentives for the nurse to report the error. This, the first of two articles, describes the results of a large-scale survey designed to assess nurses' perceptions of the reasons why MAE may not be reported. The companion article compares nurses' estimates of the extent to which MAEs are reported with the actual reported medication error rates. METHODS Nurses in 24 acute-care hospitals were surveyed to determine perceptions of reasons why medication errors may not be reported. RESULTS The factor analysis reveals four factors explaining why staff nurses may not report medication errors: fear, disagreement over whether an error occurred, administrative responses to medication errors, and effort required to report MAEs. CONCLUSIONS There are potential changes in both systems and management responses to MAEs that could improve current practice. These changes need to take into account the influences of organizational, professional, and work group culture.
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Affiliation(s)
- D S Wakefield
- Health Sciences Center, University of Iowa Health Sciences Center, Iowa City, USA
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21
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Abstract
The purpose of this study was to demonstrate the feasibility of a model of overcoming local barriers to physician peer review through development of a statewide provider-based physician peer review service. For this purpose, the cooperative demonstration project of the Institute for Quality Healthcare, The University of Iowa and The Robert Wood Johnson Foundation, was used. A consortium of 43 Iowa hospitals developed a physician peer review service utilizing a pool of physician reviewers from member hospitals. Thirty-six peer reviews were conducted in 23 different hospitals by 37 different reviewers throughout the state of Iowa in the first 2 years of operation. Reviews of surgical specialists, psychiatrists, and psychiatric services were requested most frequently. The satisfaction of hospitals with the physician peer review service has thus far been gratifying. The long-term financial viability of the physician peer review service has yet to be demonstrated. This cooperative organizational model of a provider-based physician peer review service may be reproducible and valuable to health care providers in other parts of the United States.
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Affiliation(s)
- C M Helms
- Department of Internal Medicine, University of Iowa, Iowa City 52242, USA
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Hendryx MS, Wakefield DS, Murray JF, Uden-Holman T, Helms CM, Ludke RL. Using comparative clinical and economic outcome information to profile physician performance. Health Serv Manage Res 1995; 8:213-20. [PMID: 10153270 DOI: 10.1177/095148489500800401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This paper presents strategies and empirical examples of comparative physician profiling under conditions of limited patient sample sizes and varying patient severity. A method by which clinical and cost outcomes may be evaluated simultaneously is also presented. Physician economic and clinical performance are compared using data abstracted from nine hospitals into the MedisGroups clinical information management system for inpatients treated from July, 1990 through June, 1992. The main outcome measures are comparative total and ancillary adjusted charges, and morbidity status. Results suggest that objective comparative outcome data provide useful information to assist in evaluating physician performance. A simultaneous comparison of clinical outcomes and adjusted charges identifies physicians who experience favorable outcomes at lower charges, as well as those who have higher charges and/or poorer outcomes. Strategies outlined in this paper may be of value to clinicians, governing boards, and third party payors. These strategies may be used to assist with privileging and other peer review activities when pursued proactively within a Continuous Quality Improvement framework to improve care.
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Affiliation(s)
- M S Hendryx
- Health Policy and Administration Program, Washington State University, Spokane, USA
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Abstract
Peer review is an essential mechanism for evaluating the judgment and performance of clinical providers. Reasons for conducting physician peer review range from identified quality-of-care concerns to general education. There are a variety of challenges to conducting an effective peer review, including the personal concerns of the peers conducting the reviews. This article reviews the potential uses of physician peer review, its basic methodologies, and challenges to and suggestions for obtaining effective peer review.
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Affiliation(s)
- D S Wakefield
- Graduate Program in Hospital and Health Administration, University of Iowa, Iowa City, USA
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Abstract
BACKGROUND Many health care organizations have embraced the philosophy and tools of total quality management (TQM) and continuous quality improvement (CQI) without overt linkage to existing peer review processes. Achieving total quality in an organization requires that both peer review and TQM/CQI improvement processes be effectively used. EXAMPLES Three ways of linking peer review and TQM/CQI include: 1) coordinating TQM/CQI and peer review quality improvement initiatives whenever possible; 2) expanding the focus of peer review to include assessment of the processes and systems within which the clinician functions; and 3) linking peer review and TQM/CQI improvement processes to address behavioral and attitudinal issues having economic roots.
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Affiliation(s)
- D S Wakefield
- Institute for Quality Health Care, University of Iowa, Iowa City, USA
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Helms CM, Wakefield DS, Hendryx MS. Hospital quality improvement programs: meeting the challenges of public expectations, professional responsibility, and survival in a reformed health care system. Clin Perform Qual Health Care 1994; 2:92-4. [PMID: 10139989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Affiliation(s)
- C M Helms
- University of Iowa Hospitals and Clinics, Iowa City 52242
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Wakefield DS, Cyphert ST, Murray JF, Uden-Holman T, Hendryx MS, Wakefield BJ, Helms CM. Understanding patient-centered care in the context of total quality management and continuous quality improvement. Jt Comm J Qual Improv 1994; 20:152-61. [PMID: 8032429 DOI: 10.1016/s1070-3241(16)30058-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Implementing patient-centered care (PCC) requires a fundamental shift in thinking-from how to best provide a wide variety of independent services to how to effectively combine individual service components into an integrated health care experience that meets patient needs and preferences. DISCUSSION PCC attempts to improve patient care by organizationally and physically moving selected service functions such as basic laboratory, pharmacy, admitting/discharge, medical records, housekeeping, and material support services to patient care areas, thus effecting an organizational restructuring. PCC creates teams composed of multiskilled or cross-trained individuals capable of providing more of the services directly on the patient care unit. Extensive redesign of the basic work processes as proposed by PCC advocates may result in significant changes in employee job scope, task responsibilities, professional autonomy, and reporting relationships. From the employee's perspective such changes may be neither warranted nor welcomed. Therefore, critical PCC implementation issues include obtaining employee buy-in and establishing appropriate incentive structures to facilitate the desired changes. How does PCC fit in with the popular improvement philosophies of total quality management (TQM) and continuous quality improvement (CQI)? Inherent within TQM and CQI is the belief that it is wiser to maximize efforts to design a product or process to be right the first time and to minimize resources devoted to inspection and repair caused by poor processes. PCC builds upon previous TQM/CQI health care efforts by focusing on ways to reduce the white space handoff problem by examining what, if any, changes in underlying structures and processes may be required. In the PCC hospital, TQM/CQI can function as intended, as a methodology for examining and improving the process of care and patient-care outcomes, regardless of internal departmental or profession-based organizational boundaries. CONCLUSION For hospitals to remain competitive in today's rapidly changing environment, it is becoming necessary to reevaluate both how they are organized and how their work processes have been designed and controlled. The groundwork already laid by TQM/CQI initiatives will facilitate the more fundamental and long-lasting improvements derived from the redesign of the patient-care unit as prescribed by the goals of PCC.
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Affiliation(s)
- D S Wakefield
- Graduate Program in Hospital and Health Administration, University of Iowa, Iowa City 52242
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Abstract
OBJECTIVE To assess whether vital sign measurements could identify internal medicine patients at risk for cardiopulmonary arrest. DESIGN Retrospective case-control study comparing 72 hours of pre-arrest vital sign measurements with 72 hours of vital sign measurements for patients from the same units who did not experience cardiopulmonary arrest. SETTING Twelve non-intensive care internal medicine units at a large midwestern academic medical center. PATIENTS Cases included all 59 inpatients who had experienced cardiopulmonary arrest between May 1989 and December 1990; patients who were designated do-not-resuscitate (DNR) or had less than 72 hours of vital sign recordings were excluded. Controls included 91 inpatients without cardiopulmonary arrest who were matched for units and who had 72 hours of vital sign recordings. RESULTS The occurrence of one or more respiratory rates > 27 breaths per minute over a 72-hour period had a sensitivity of 0.54 and a specificity of 0.83 (odds ratio = 5.56, 95% CL = 2.67-11.49) in predicting cardiopulmonary arrest. Other respiratory rate thresholds were also predictive of arrest. The ability of respiratory rate to predict arrest was stronger in units with high incidences of arrest relative to units with low incidences, for example, in units for the management of gastrointestinal disease (sensitivity = 1.00, specificity = 0.86) and renal disease (sensitivity = 0.69, specificity = 0.87). Respiratory rate remained a significant predictor (p < 0.001) after controlling for patient age and gender. Pulse rate and blood pressure were not predictive of cardiopulmonary arrest. CONCLUSIONS Using elevated respiratory rates as a signal for focused diagnostic studies and therapeutic interventions in internal medicine patients may be useful in reducing the incidence of subsequent cardiopulmonary arrest, and lowering associated morbidity and mortality.
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Affiliation(s)
- J F Fieselmann
- Department of Internal Medicine, University of Iowa, Iowa City 52242
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Abstract
Many health care organizations are attempting to rapidly implement total quality management (TQM) and continuous quality improvement (CQI) philosophies and concepts. In the case of hospitals, a number of issues resulting from traditional organizational design and management practices as well as the characteristics of health care professionals pose significant challenges to rapid implementation. Recognizing and developing strategies to address these challenges, along with realizing that TQM and CQI represent viable processes for conducting organizational "preventive maintenance," may help in changing the focus of quality assessment and enhancement initiatives from processes that are "broken" to processes that should be "fixed" before they "break." This article discusses strategies for overcoming some of the major barriers and challenges to successful TQM and CQI implementation to the hospital setting.
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Affiliation(s)
- D S Wakefield
- Graduate Program in Hospital and Health Administration, University of Iowa, Iowa City 52242
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Hendryx MS, Rohrer JE, Fieselmann JF, Wakefield DS, Helms CM. Methods of determining the prevalence of changes in vital signs among internal medicine inpatients. Clin Perform Qual Health Care 1993; 1:17-22. [PMID: 10135604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
OBJECTIVE To investigate the prevalence of changes in vital signs and methods of summarizing these changes. DESIGN A survey of vital sign values for all eligible inpatients over a three-day period. PATIENTS All 91 patients who remained for an entire three-day period in January 1991 on 1 of 11 nonintensive care internal medicine units in the medical center. RESULTS Prevalence of changing vital signs varied by type of vital sign, inpatient unit, and method of computation. A method of computation that relies on daily extreme vital sign values. Pulse rates and blood pressure were more variable than respiratory rates. CONCLUSIONS Mean daily pulse rates and blood pressure may be useful for quality assessment purposes, whereas individual readings may be more appropriate for respiratory rates. Computation of expected rates of changing vital signs should be tailored to inpatient unit type.
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Wakefield DS, Ludke RL, Rohrer JE, Booth BM, Breese S, Moen A, Fortney J, Zeitler R. Shifting the financial burden: the VA ambulatory care discharge policy. Health Serv Manage Res 1992; 5:162-72. [PMID: 10122810 DOI: 10.1177/095148489200500301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Department of Veterans Affairs is a primary source of health care services for many of the nation's uninsured and underinsured. Changes in congressionally mandated eligibility criteria and limited increases in appropriations have forced the Department to adopt a policy of discharging chronic but stable outpatients who have been treated for non-service-connected health conditions. Survey data from one VA medical center suggest that many, but not all, of those discharged: 1) have either Medicare or private insurance coverage; 2) have not sought or found alternative physician services in their local communities; 3) have discontinued taking previously prescribed medications; 4) report worsened health status since discharge; and, 5) have been hospitalized. In general, discharged patients from the lowest income group report the greatest financial access barriers. Preliminary analyses of the discharge policy suggest the potential for decreased access to needed medical services due to financial factors and cost-shifting from the VA to patients and other federal, state and local payers and providers.
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Affiliation(s)
- D S Wakefield
- College of Medicine and Graduate College, University of Iowa, Iowa City
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31
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Abstract
While there is little agreement at the individual patient level of analysis, estimates of mean NI-attributed days of stay for the two methods were essentially the same. The lack of agreement at the individual patient level may reflect fundamental differences in the methods used to derive these estimates: incorporation of noninfected patient data versus exclusive reliance on data from infected patients; and, focus on length of stay rather than the actual care being received. The potential advantages of the AEP-based method include the following: 1) all patients with NI can be included in developing estimates; 2) estimates are based on the care provided rather than simple length of stay differences; 3) data on which to form the NI-day estimates are readily available in the medical record; 4) the AEP is a validated and commonly used utilization review instrument; 5) the AEP-based method has acceptable reliability; 6) this method is designed to provide individual and group estimates of NI-attributed days; 7) because every day of stay is reviewed, additional information is available, which results in greater precision of study of the development, diagnosis, and treatment of the NI relative to the other care that originally brought the patient into the hospital. The AEP-based method for estimating NI-days is a promising alternative to the historical cohort approach. Additional applications of this approach are encouraged to further assess its reliability,validity, and additional information yield.
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Affiliation(s)
- D S Wakefield
- Graduate Program in Hospital and Health Administration, University of Iowa, Iowa City 52242
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Wakefield B, Wakefield DS, Booth BM. Evaluating the validity of blood glucose monitoring strip interpretation by experienced users. Appl Nurs Res 1992; 5:13-9. [PMID: 1570952 DOI: 10.1016/s0897-1897(05)80078-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
This study examined interpretations of blood glucose monitoring strips (BGMS) by patients and registered nurses (RNs) experienced in strip use. Visual interpretations of whole and bisected BGMS were compared with readings obtained with a reflectance meter. For whole strips, statistically significant differences were found when mean values of patient interpretations were compared with two of the three RNs and the meter. A significant difference was found between the average meter values and those for a third RN. When bisected strips were interpreted, a significant interaction effect was found between reader and strip condition. The RNs systematically underestimated bisected strips when compared with whole strips, whereas patients consistently underestimated both whole and bisected strips. The findings support the need for development of quality assurance monitors to evaluate users of patient self-care technologies such as BGMS.
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Pfaller MA, Wakefield DS, Hollis R, Fredrickson M, Evans E, Massanari RM. The clinical microbiology laboratory as an aid in infection control. The application of molecular techniques in epidemiologic studies of methicillin-resistant Staphylococcus aureus. Diagn Microbiol Infect Dis 1991; 14:209-17. [PMID: 1889173 DOI: 10.1016/0732-8893(91)90034-d] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A microbiologic surveillance study was performed in order to estimate the point prevalence, source, and nosocomial acquisition of methicillin-resistant Staphylococcus aureus (MRSA) within the Iowa City Veterans Affairs Medical Center (IC VAMC). Immediately following the microbiologic surveillance study, a cluster of nosocomial MRSA infections was detected by routine infection control surveillance. An epidemiologic investigation was conducted and all isolates of MRSA detected during the microbiologic surveillance study and the subsequent cluster of nosocomial infections were characterized by restriction endonuclease analysis of plasmid DNA (REAP). REAP subtyping defined a total of ten distinct subtypes from 24 patients infected or colonized with MRSA. The documentation of a single subtype of MRSA (subtype A2) in nine patients from the surgical service, eight of which were hospitalized in the surgical intensive care unit, provided convincing evidence of a breakdown of infection control practices in that unit. REAP subtyping was a highly discriminating means of identifying different subtypes among the various isolates of MRSA and was useful in directing infection control efforts to specific problem areas within the hospital. Molecular typing methods, such as REAP, when used appropriately in conjunction with careful epidemiologic investigation provide an effective approach to the investigation and control of the spread of MRSA within the hospital.
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Affiliation(s)
- M A Pfaller
- Veterans Affairs Medical Center, Iowa City, Iowa
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34
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Schwartz DA, Wakefield DS, Fieselmann JF, Berger-Wesley M, Zeitler R. The occupational history in the primary care setting. Am J Med 1991; 90:315-9. [PMID: 2003513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE To assess the need for services in occupational medicine, we determined the prevalence of reported occupational exposures in patients seen in the primary care setting. In addition, we evaluated the validity of our survey instrument. PATIENTS AND METHODS All patients (n = 1,112) seen over a 3-month period of time in the Primary Care Clinic at the Iowa City Veterans Affairs Medical Center were considered eligible for this study. A survey instrument was developed to obtain specific information regarding occupational exposures. The questionnaire was administered to 534 or 48% of all eligible patients. The validity of the survey instrument was evaluated by comparing chest radiographs in subjects with a history of exposure to asbestos, coal dust, or silica to those in patients who were not exposed to any of these agents. RESULTS We found that almost 75% of the patients reported prior occupational exposure to at least one potentially toxic agent, and over 30% claimed exposure to at least four potentially toxic agents. The validation study indicated that the reported exposure history for asbestos, coal dust, and silica is significantly associated with anticipated changes on chest radiographs. These findings suggest that this easily administered survey instrument is valid for pneumoconiotic dust exposures and may also be valid for other potentially toxic exposures. CONCLUSION Data from our study indicate that patients seen in the ambulatory care setting may have clinically significant occupational exposures that are relevant to their medical condition.
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Affiliation(s)
- D A Schwartz
- Department of Internal Medicine, University of Iowa, College of Medicine, Iowa City 52242
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35
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Wakefield DS. Rural hospitals and the provision of agricultural occupational health and safety services. Am J Ind Med 1990; 18:433-42. [PMID: 2248247 DOI: 10.1002/ajim.4700180414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Agriculture is one of the most dangerous work environments in the United States. Ironically, there is a near-total absence of occupational health and safety services being provided to agricultural workers. While many of the agricultural occupational hazards could be addressed through health and safety services provided by rural hospitals, the absence of dedicated funds to pay for these services is a major barrier. The ability of rural hospitals to provide these services and specific issues related to the unique character and problems in implementing agricultural occupational health and safety services are discussed.
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Wakefield B, Wilberding JZ, Wakefield DS, Booth BM, Buckwalter KC. Does contamination affect the reliability and validity of bisected chemstrip bGs? West J Nurs Res 1989; 11:328-33. [PMID: 2750144 DOI: 10.1177/019394598901100307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Wakefield DS, Ludke RL. Developing an ambulatory care risk management (ACRM) program. J Ambul Care Manage 1988; 11:77-87. [PMID: 10303013 DOI: 10.1097/00004479-198811000-00011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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38
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Massanari RM, Pfaller MA, Wakefield DS, Hammons GT, McNutt LA, Woolson RF, Helms CM. Implications of acquired oxacillin resistance in the management and control of Staphylococcus aureus infections. J Infect Dis 1988; 158:702-9. [PMID: 3049836 DOI: 10.1093/infdis/158.4.702] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Refinements in testing for resistance to penicillinase-resistant penicillins (PRP) in Staphylococcus aureus have resulted in confusion in classifying isolates as PRP susceptible or resistant. Specifically, a group of organisms has been identified that produce large amounts of beta-lactamase and appear borderline resistant. These organisms have been called "occult resistant" or "acquired oxacillin-resistant" S. aureus (AORSA). A retrospective study was conducted to evaluate the implication of this in vitro phenomenon in managing patients with AORSA infections. Among 134 patients with S. aureus infections, 89 were infected with oxacillin-susceptible S. aureus (OSSA), 26 with AORSA, and 19 with oxacillin-resistant S. aureus (ORSA). There were no significant differences in outcomes when OSSA and AORSA infections were treated with PRP (chi 2MH = .990; P = .32). These results do not suppor the contention that AORSA infections should be managed differently from OSSA infections. Identifying AORSA may not be helpful in guiding antimicrobial therapy or predicting the outcome of infections with AORSA.
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Affiliation(s)
- R M Massanari
- Department of Internal Medicine, University of Iowa College of Medicine
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39
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Wakefield DS, Helms CM, Massanari RM, Mori M, Pfaller M. Cost of nosocomial infection: relative contributions of laboratory, antibiotic, and per diem costs in serious Staphylococcus aureus infections. Am J Infect Control 1988; 16:185-92. [PMID: 3264121 DOI: 10.1016/0196-6553(88)90058-2] [Citation(s) in RCA: 76] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
This study reports an analysis of the relative importance of laboratory antibiotic, and per diem costs of caring for 58 patients with serious Staphylococcus aureus nosocomial infections. Laboratory costs accounted for 2%, antibiotics for 21%, and per diem costs for 77% of total infection-related costs. Only 45% of patients were hospitalized for additional days specifically because of infection, but these patients stayed an average of 18 extra days. Nosocomial infections with S. aureus resistant to penicillinase-resistant penicillins (PRP) were more frequently associated with additional infection-related days of hospitalization than were PRP-susceptible infections. The cost of PRP-resistant infections was also significantly greater than PRP-susceptible infections, primarily because of the costs of additional days of hospitalization. Rational strategies to control costs of nosocomial infection should focus on two approaches: (1) prevention and (2) reduction of acute hospital days attributable to infections.
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Affiliation(s)
- D S Wakefield
- Department of Hospital and Health Administration, University of Iowa College of Medicine
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40
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Wakefield DS, Curry JP, Price JL, Mueller CW, McCloskey JC. Differences in work unit outcomes. Job satisfaction, organizational commitment, and turnover among hospital nursing department employees. West J Nurs Res 1988; 10:98-105. [PMID: 3369169 DOI: 10.1177/019394598801000110] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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41
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Pfaller MA, Wakefield DS, Stewart B, Bale M, Hammons GT, Massanari RM. Evaluation of laboratory methods for the classification of oxacillin-resistant and oxacillin-susceptible Staphylococcus aureus. Am J Clin Pathol 1988; 89:120-5. [PMID: 3276141 DOI: 10.1093/ajcp/89.1.120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
The purpose of this study was to examine the efficacy of the oxacillin disk diffusion test and the methicillin and oxacillin agar screen tests as predictors of oxacillin resistance as defined by the reference broth microdilution method. A total of 444 clinical isolates of Staphylococcus aureus collected from individual patients over a four-year period were tested by (1) the oxacillin disk diffusion test, with particular attention to the presence of fine growth of a resistant subpopulation within the zone of inhibition (Ox Grow interpretive criteria); (2) the agar screen method using agar plates with 4% NaCl and either 6 mg/L oxacillin or 10 mg/L methicillin; and (3) the oxacillin and methicillin broth microdilution test methods with 2% NaCl supplementation. Overall, 62 (14%) isolates were resistant and 382 (86%) isolates were susceptible to oxacillin with the use of the reference broth microdilution system. The results indicate that the disk diffusion test with the use of the Ox Grow criteria had a high sensitivity (94%) and negative predictive value (98%) but a low specificity (67%) and positive predictive value (32%) when compared with the reference broth dilution test. Similarly, the agar screen tests had a high sensitivity (95-97%) and negative predictive values (99%) but low specificity (64-74%) and positive predictive values (30-37%). These data indicate that the agar screen tests and the oxacillin disk test with the use of the Ox Grow interpretive criteria may be useful as screening tests for detecting resistance to the penicillinase-resistant penicillins but that all resistant isolates should be confirmed by the reference broth dilution method because of the large number of false-resistant screening test results.
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Affiliation(s)
- M A Pfaller
- Veterans Administration Medical Center, Iowa City, Iowa
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42
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Pfaller MA, Wakefield DS, Hammons GT, Massanari RM. Variation from standards in Staphylococcus aureus susceptibility testing. Am J Clin Pathol 1987; 88:231-5. [PMID: 3618554 DOI: 10.1093/ajcp/88.2.231] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
In an effort to assess the degree of methodologic variation and adherence to current guidelines for detection of methicillin-resistant Staphylococcus aureus (MRSA), the authors surveyed the susceptibility testing practices of all 162 microbiology laboratories in the Veterans Administration (VA) system. Completed questionnaires were returned by 136 (84%) of the laboratories. Overall, 96 (71%) laboratories used disk diffusion testing, 54 (40%) used manual broth dilution, and 36 (26%) used an automated method. The percentage of MRSA detected ranged from 0 to 52%, with a mean of 10%. In general, fewer than 60% of laboratories followed the current susceptibility testing guidelines for key methodologic variables such as inoculum preparation, duration of incubation, and medium supplementation. Failure to adhere to these guidelines may result in suboptimal detection of MRSA.
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Wakefield DS, Pfaller MA, Hammons GT, Massanari RM. Use of the appropriateness evaluation protocol for estimating the incremental costs associated with nosocomial infections. Med Care 1987; 25:481-8. [PMID: 3695657 DOI: 10.1097/00005650-198706000-00003] [Citation(s) in RCA: 33] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Existing methods for estimating additional days of hospital stay due to nosocomial infections (NI) have a number of documented limitations. An alternative method described in this paper uses the Appropriateness Evaluation Protocol (AEP) to determine whether each day of acute inpatient care is appropriate based on the need for care of the NI, original cause of hospitalization (OC), or combined NI-OC requirements. Using this method to identify specific days of hospitalization due to Staphylococcus aureus nosocomial infection, we find: 1) length of stay is increased for only a minority of patients (38%); 2) an average of 20 additional days of stay occurred for patients with 1 or more days attributed to NI; and 3) an average of 52% of length of stay of patients with 1 or more days attributed to NI can be attributed to the NI. Application of the AEP-based method is a useful alternative for identifying additional days of stay due to NI.
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Affiliation(s)
- D S Wakefield
- Graduate Program in Hospital and Health Administration, University of Iowa, Iowa City 52242
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Wakefield DS, Curry JP, Kieffer SE. Organizational and operational characteristics of hospice programs in Iowa: considering the future with a look at the present. Am J Hosp Care 1987; 4:35-42. [PMID: 3646896 DOI: 10.1177/104990918700400315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Wakefield DS, Pfaller M, Massanari RM, Hammons GT. Variation in methicillin-resistant Staphylococcus aureus occurrence by geographic location and hospital characteristics. Infect Control 1987; 8:151-7. [PMID: 3647007 DOI: 10.1017/s0195941700065814] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
A survey of 162 Veterans Administration Medical Center (VAMC) laboratories performing antimicrobial susceptibility testing was performed to determine variation in reported rates of methicillin-resistant Staphylococcus aureus (MRSA) isolation by geographic location and hospital characteristics. Of the 162 VAMC laboratories surveyed, 136 (84%) provided usable data. The percentage of S aureus isolates reported as resistant to methicillin ranged from 0% to 52% with a mean value of 10% among the 136 survey respondents. MRSA were isolated in every VA Medical District and 96% of all respondent laboratories reported isolating at least one MRSA isolate during the preceding year. These data are considered an underestimate of the time MRSA rate in the VA system due to the fact that many laboratories failed to follow key methodologic guidelines for optimal detection of MRSA. A positive correlation was found between MRSA isolation rate and several measures of hospital size and activity including total beds, total admissions, and total antimicrobial susceptibility tests performed. Geographic clustering of MRSA isolation was observed with distinct areas of very high and very low percentages of S aureus isolates reported as MRSA. The data suggest that the geographic distribution of MRSA within the VA system should be monitored closely for evidence of spread from areas with high-MRSA rates to areas of mid- or low-MRSA rates. Evidence of increased MRSA isolation within these areas may necessitate increased caution in patient referral and transfer patterns within the VA system.
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Hoffman F, Wakefield DS. Ambulatory care patient classification. J Nurs Adm 1986; 16:23-30. [PMID: 3083055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Efficient, cost-effective use of resources is important in every aspect of health care. As ambulatory care continues to grow, it becomes an increasingly important area for managerial attention. Few tools which are specific to the outpatient environment have been developed. This paper has suggested an approach to developing a specific instrument to assist in controlling costs in the ambulatory unit: the ambulatory patient classification system.
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Abstract
A causal model of turnover, or quitting, among hospital nursing department employees was evaluated. This model includes job satisfaction, organizational commitment, and intent to leave as intervening variables that mediate 13 determinants of turnover. The sample consisted of 841 female nursing department employees selected from five hospitals in a western state. Attitudinal and background data were obtained through a mail questionnaire survey, and turnover was monitored for 18 months following the survey. Intent to leave had a strong direct effect on turnover while kinship responsibility, job satisfaction, and organizational commitment had indirect effects on turnover through intent to leave. Task repetitiveness, autonomy, promotional opportunities, and fairness of rewards were important determinants of jobs satisfaction and thus provide a mechanism whereby hospital management may enhance commitment to the organization while reducing turnover.
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Wakefield DS, Mathis S. Formulating a managerial strategy for part-time nurses. J Nurs Adm 1985; 15:35-9. [PMID: 3917494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The implementation of the federal Medicare Diagnosis Related Groupings (DRGs)-based prospective payment system (PPS) has caused nursing administrators to examine staffing policies and strategies closely. A critical component under nursing management's control is the use of part-time nurses to solve scheduling, cost, and quality-of-care problems. This article analyzes past and future use of part-time nurses.
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Wakefield DS. Findings of teaching aids study are inaccurate. Am J Occup Ther 1981; 35:668-9. [PMID: 7294138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
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