NT: Nurses urged to use checklists to reduce human error in practice

Last month Nursing Times included an item on checklists, highlighting work by the WHO in perioperative nursing and the Patient Safety First campaign. Following surgery's lead is the realisation that similar checklists have the potential to improve communication and team working in other areas such as nutrition, situational awareness and pressure ulcer care.

Checklists are ubiquitous in our day-to-day lives, the dividend for using them is fairly obvious. What is less obvious is the fact that checklists alone are dead bureaucratic adornments. Checklists are animated by situations and thinking, reflective individuals in those situations. As Lomas reports there is a need to stop at an agreed key point in the patient pathway and ask the critical - checklist - questions. In team work this co-ordinated acknowledgement to complexity is essential for comprehensive, consistent and safe care.

What is interesting here is the emphasis on human factors. While checklists undoubtedly have a demonstrated - proven - role to play in safety, situational awareness is not a product of checklists alone. There is a need for learning and for the cultivation of cognitive lists. While human memory is fallibility incarnate - hence the role for checklists - there is also the need for skilled, knowledgeable professionals with the required communication and observational skills. The need for nurses to further develop observational skills has also been highlighted over recent months.

So as checklists are checked and logged: prepare a space for the mental checklist that is Hodges' model. The model is situated, person-centered and one of the original purposes was to help bridge the theory - practice gap. Try doing that with a checklist: alone

Clare Lomas Safety checklists could cut 'human error' in clinical practice, Nursing Times, 106, 3, 26 January 2010, p.2.

Hospital Characteristics Associated With Feeding Tube Placement in Nursing Home Residents With Advanced Cognitive Impairment

Joan M. Teno, MD, MS; Susan L. Mitchell, MD, MPH; Pedro L. Gozalo, PhD; David Dosa, MD, MPH; Amy Hsu, BA; Orna Intrator, PhD; Vincent Mor, PhD

JAMA. 2010;303(6):544-550.

Context Tube-feeding is of questionable benefit for nursing home residents with advanced dementia. Approximately two-thirds of US nursing home residents who are tube fed had their feeding tube inserted during an acute care hospitalization.

Objective To identify US hospital characteristics associated with higher rates of feeding tube insertion in nursing home residents with advanced cognitive impairment.

Design, Setting, and Patients The sample included nursing home residents aged 66 years or older with advanced cognitive impairment admitted to acute care hospitals between 2000 and 2007. Rate of feeding tube placement was based on a 20% sample of all Medicare Claims files and was assessed in hospitals with at least 30 such admissions during the 8-year period. A multivariable model with the unit of the analysis being the hospital admission identified hospital-level factors independently associated with feeding tube insertion rates, including bed size, ownership, urban location, and medical school affiliation. Measures of each hospital's care practices for all patients with serious chronic illnesses were evaluated, including intensive care unit (ICU) use in the last 6 months of life, the use of hospice services, and the ratio of specialist to primary care physicians. Patient-level characteristics were also considered.

Main Outcome Measure Endoscopic or surgical insertion of a gastrostomy tube during a hospitalization.

Results In 2797 acute care hospitals with 280 869 admissions among 163 022 nursing home residents with advanced cognitive impairment, the rate of feeding tube insertion varied from 0 to 38.9 per 100 hospitalizations (mean [SD], 6.5 [5.3]; median [interquartile range], 5.3 [2.6-9.3]). The mean rate of feeding tube insertions per 100 admissions was 7.9 in 2000, decreasing to 6.2 in 2007. Higher insertion rates were associated with the following hospital features: for-profit ownership vs government owned (8.5 vs 5.5 insertions per 100 hospitalizations; adjusted odds ratio [AOR], 1.33; 95% confidence interval [CI], 1.21-1.46), larger size (>310 beds vs <101> insertions per 100 hospitalizations; AOR, 1.48; 95% CI, 1.35-1.63), and greater ICU use in the last 6 months of life (highest vs lowest decile: 10.1 vs 2.9 insertions per 100 hospitalizations; AOR, 2.60; 95% CI, 2.20-3.06). These differences persisted after controlling for patient characteristics. Specialist to primary care ratio and hospice use were weakly or not associated with feeding tube placement.

Conclusion Among nursing home residents with advanced cognitive impairment admitted to acute care hospitals, for-profit ownership, larger hospital size, and greater ICU use was associated with increased rates of feeding tube insertion, even after adjusting for patient-level characteristics.

Author Affiliations: Center for Gerontology and Health Care Research, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island (Drs Teno, Gozalo, Dosa, Intrator, and Mor and Ms Hsu); Institute for Aging Research, Hebrew Senior Life, Harvard Medical School, Boston, Massachusetts (Dr Mitchell); and Providence Veterans Affairs Medical Center, Providence, Rhode Island (Drs Dosa and Intrator).