Nursing Morbidity and Mortality

Abstract

Nursing M&M has been well attended over the past year. Since its inception, multiple practice changes have been implemented. Based on the positive feedback from the evaluations, this monthly conference has become standing practice in the institution.

Clinical Nurse Peer Review

“…Many processes described in the literature rely upon individual referral 8,9,11,15 or cases identified in a database of quality indicators. 7,10 In situations where events were identified in a safety reporting platform, the criterion or strategy for selection was not described. This creates opportunity for events to fall through the cracks.…”

“…In a process described by Korkis et al, 11 a staff nurse facilitator was associated with involved nurses' comfort during the peer review experience, compared with feelings of discomfort evaluated prior to the review. 10 It is difficult to assess the impact of a peer facilitator on the involved nurse's experience with CPR, due to variability in outcomes measured and structure of CPR in prior studies. In situations where CPR was led by a leader, the involved nurse may not have been included in the review for evaluation.…”

“…9 This discussion might be limited to select members of a committee 9 or open to any clinical staff who want to participate. 10 A number of references suggest that reviews are facilitated by a formal leader and do not require the nurse(s) involved in the case to attend. 9,10 Each of these practices has the potential to influence how the peer review process is perceived by nurses and can serve as a barrier when the intent is viewed as punitive, rather than one of discovery in pursuit of systematic improvement.…”

“…9 Others described how cases are selected by way of a safety event reporting system 9 or in databases, such as the National Database for Nursing Quality Improvement ® . 10 Primarily, organizations with a CPR process report that review of events is retrospective in nature and takes place after a negative event has occurred. 8 Near-miss events are generally not included, which may provide an opportunity to make proactive changes that prevent an error from occurring.…”

Addressing CAUTIs with an External Female Catheter

“…In the current health care system, nursing interventions that emphasize quality of care and improved patient outcomes are often seen to have positive effects, not only clinically but financially. 12 As leaders in preventing hospital-acquired conditions, CNSs help improve the quality of patient care and reduce overall health care costs. CNSs are well prepared to implement evidencebased initiatives that could benefit nursing practice and hospital-based QI initiatives.…”