Accepted Manuscript Title: Implications for patient safety in the use of safe patient handling equipment: A national survey Author: Christine A. Elnitsky Jason D. Lind Deborah Rugs Gail Powell-Cope PII: DOI: Reference:

S0020-7489(14)00108-4 http://dx.doi.org/doi:10.1016/j.ijnurstu.2014.04.015 NS 2390

To appear in: Received date: Revised date: Accepted date:

25-11-2013 13-4-2014 23-4-2014

Please cite this article as: Elnitsky, C.A., Lind, J.D., Rugs, D., PowellCope, G.,Implications for patient safety in the use of safe patient handling equipment: A national survey, International Journal of Nursing Studies (2014), http://dx.doi.org/10.1016/j.ijnurstu.2014.04.015 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Implications for patient safety in the use of safe patient handling equipment: A national survey Christine A. Elnitsky, PhD, RN (corresponding author)

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Associate Professor, School of Nursing, College of Health and Human Services, The University of North Carolina at Charlotte, 9201 University City Blvd. Charlotte, NC.

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Research Associate, Health Services Research and Development & Rehabilitation Research and Development Center of Innovation for Disability and Rehabilitation Research (CIDRR8), James A. Haley Veterans Hospital, Tampa, FL. James A. Haley Veterans’ Hospital 8900 Grand Oak Circle Tampa, FL United States, [email protected] ; 727-512-1208; Fax 704-687-1657

Jason D. Lind, PhD

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Anthropologist, Health Services Research and Development & Rehabilitation Research and Development Center of Innovation for Disability and Rehabilitation Research (CIDRR8), James A. Haley Veterans Hospital, Tampa, FL.

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Deborah Rugs, PhD

Gail Powell-Cope, PhD, ARNP, FAAN

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Health Science Specialist, Health Services Research and Development & Rehabilitation Research and Development Center of Innovation for Disability and Rehabilitation Research (CIDRR8), James A. Haley Veterans Hospital, Tampa, FL.

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Director, Health Services Research and Development & Rehabilitation Research and Development Center of Innovation for Disability and Rehabilitation Research (CIDRR8), James A. Haley Veterans Hospital, Tampa, FL.

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ABSTRACT

Background

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The prevalence of musculoskeletal injuries among nursing staff has been high due to patient

handling and movement. Internationally, healthcare organizations are integrating technological

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equipment into patient handling and movement to improve safety. Although evidence shows that

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not clear how safe these new programs are for patients.

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safe patient handling programs reduce work-related musculoskeletal injuries in nursing staff, it is

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Objectives

The objective of this study was to explore adverse patient events associated with safe patient

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Methods

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handling programs and preventive approaches in U.S. Veterans Affairs medical centers.

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The study surveyed a convenience sample of safe patient handling program managers from 51 U.S. Department of Veterans Affairs medical centers to collect data on skin-related and fallrelated adverse patient events.

Results

Both skin- and fall-related adverse patient events associated with safe patient handling occurred at VA Medical centers. Skin-related events included abrasions, contusions, pressure ulcers and lacerations. Fall-related events included sprains and strains, fractures, concussions and bleeding.

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Program managers described contextual factors in these adverse events and ways of preventing the events.

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Conclusions

The use of safe patient handling equipment can pose risks for patients. This study found that

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organizational factors, human factors and technology factors were associated with patient

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adverse events. The findings have implications for how nursing professionals can implement safe

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patient handling programs in ways that are safe for both staff and patients.

Keywords: moving and lifting, nursing, quantitative analysis, qualitative analysis, safety,

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supplies and equipment, technology, wounds and injuries

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1. Introduction Nursing staff in medical facilities experience high rates of work-related musculoskeletal injury

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associated with lifting, positioning, and transferring patients. In 2010, the U.S. Occupational Safety and Health Administration reported an injury rate of 247 per 10,000 healthcare workers

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(27,020 cases) (U.S. Department of Labor, 2014). In 2008, the U.S. Department of Veterans Affairs (VA) launched a system-wide, safe patient handling (SPH) program to reduce these

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injuries in nursing staff who provide direct patient care. However, while the use of new

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technologies prevents musculoskeletal injuries in nurses (Nelson and Baptiste, 2004), it is not clear how safe the technologies are for patients (deRuiter and Liaschenko, 2011). These same

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technologies may introduce unintended adverse patient events such as skin-related or fall-related

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patient injuries (Ali and Glenister, 2001; deRuiter, 2006; Powell-Cope et al., 2008).

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The “decision making process for patient lifting is a moving target as new technology introduces

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the potential for new and different errors” (Wright et al., 2005 p. 28). For example, manufacturers have produced a variety of types of lift equipment and slings that go with each piece of equipment (Baptiste et al., 2008). Although manufacturers require the use of their own slings with their equipment, this rule may not always be followed. The use of the same size sling from different manufacturers can create different sitting positions for the same patient; because sling size is not standard. Staff also need to be aware of the specific weight limits and patient body weight distribution for various manufacturers’ equipment (Nelson et al, 2009). Slings without adequate leg support may permit patients to slip through the sling (Alamgir et al, 2008). In addition, there are concerns about patient comfort and dignity when sitting with legs wide apart in a sling. Slings in poor repair may be broken, frayed, or torn; hence they must be 4 Page 4 of 40

inspected with each use (Nelson et al, 2009). Also, proper attachment of slings to equipment is important. For example, if a sling hook is attached to the wrong point on the spreader bar frame, the uneven sling makes an unsafe seating arrangement for the patient. Pain in the patient’s arms

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or back may be associated with the use of standing slings if there are pinch points or undue pressure over bony prominences, or if the patient’s clothing becomes caught in the sling

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(Baptiste et al., 2008).

Thus there is the potential for incorrectly choosing a sling for use with the lifting, transferring

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and repositioning equipment (Wright et al., 2005). Further, there are 23 patient conditions affecting sling choice; and the sling choice must take into account wounds, amputations, bariatric

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issues, burns, fractures, presence of tubes, and more. Some patients, such as patients with hip

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pain or distress, require different degrees of trunk-to-thigh angle. The characteristics of patients

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must be considered in lifting decisions, including their ability to bear weight and their ability to understand or follow instructions. Decision making during such procedures must consider patient

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characteristics, such as their ability to bear weight or their ability to understand or follow instructions. All of these factors are decision making points that go into the activity of lifting a patient.

In the United Kingdom, 446 adverse patient incidents involving lift equipment were reported over a 10 year period by the Medical Devices Agency (Ali and Glenister, 2001), a voluntary reporting agency. Fourteen patient deaths and 18 serious physical injuries were among these incidents. Further analyses of reported patient incidents resulted in the identification of related causes, defined as

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(1) Suitability and correct operation of equipment: proper weight distribution of the patient is essential; atrophy or amputation can lead to uneven distribution of patient weight or patient not being held correctly in the sling.

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(2) Patient cooperation: staff must coach and instruct patients where to place their hands or hold on during lifting, but a patient may be unable (dementia) or unwilling

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(anxiety) to follow instructions.

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(3) Device wear and tear: this can result in failure of sling straps and attachment clips causing injuries.

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(4) User training: Lack of competency assessment or borrowing equipment from other units where the user has no knowledge of procedures can cause adverse incidents.

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Awareness of such incidents and their causes can support appropriate use of lifting

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equipment and facilitate vigilance among users (Ali and Glenister, 2001).

Analysis of clinical incidents reported in the UK estimated a 2008 incidence of 0.2% of patient

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injuries being associated with patient movement and handling (Cornish and Jones, 2012). While selected trauma were identified from the incident reports, the focus was mainly on fall-related injuries and reports did not address specific contextual factors and prevention methods.

In the United States, adverse patient events have been voluntarily reported through the Food and Drug Administration, Manufacturer and User Facility Device Experience (MAUDE) data base since June 2003. Approximately 193 patient injuries associated with power lift equipment were reported in the 6 year period from January 2005 to June 2011 (FDA, 2001a). Among these were 38 patient deaths associated with the category of “AC-powered lift patient”

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FDA, 2011b). For example, on April 4, 2011, a patient was injured as they were being transferred from the bed to his wheelchair via a Hoyer lift; the right shoulder strap tore away from the pad, and as a result the patient fell to the floor and sustained a left hip fracture (FDA,

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2011c). For the same time period in the category “lifting, patient, non-AC powered,” there were 343 injuries and 65 deaths (FDA, 2011c1; FDA, 2011c2). This category includes lateral lifts, or

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slides, and mobile lifts that have a rechargeable battery. A patient died from this type of

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equipment as aids were transferring them from the bed to a wheelchair using a portable ceiling lift; one of the leg straps came undone, and the patient fell out of the sling and broke a leg. The

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patient died 5 days after the incident (FDA, 2011c3).

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Equipment may also be used incorrectly, putting patients at risk. Researchers have found that

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patient injuries may be attributed to lack of staff training in the use of equipment. Staff turnover,

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lack of time to reinforce training on the nursing unit (Koppelaar et al., 2009), and using lifting equipment that is incompatible with the staff culture (Swain et al., 2003) have been shown to

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contribute to adverse events.

There has been limited empirical research focusing on adverse patient events associated with safe patient handling programs. The National Center for Patient Safety (NCPS) and the U.S. Food and Drug Administration (FDA) collaborate to collect data on patient safety events associated with patient handling equipment (personal communication, Joan Todd, FDA). However, the FDA depends on a voluntary device manufacturer reporting system and thus may not obtain data on contextual factors that affect adverse events, or provider-perceived conditions. The purpose of this project was to explore adverse patient events and approaches to preventing

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such events, specifically in Department of Veterans Affairs Medical Centers, where a safe patient handling program has been implemented nationwide. 1. Methods

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2.1 Design and sample

This study employed a cross-sectional survey design. The participants were composed of safe

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patient handling (SPH) program managers responsible for coordinating the program in all 153

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medical centers in the largest national healthcare system in the United States; that is the Department of Veterans Affairs Medical Centers (VAMC). The entire population of VAMC SPH

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program managers were invited to participate in the study via email invitations sent by the SPH National Program Evaluation project manager to all 141 VA SPH program managers.

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Consequently, 141 program managers from 153 hospitals were asked to participate in the study,

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and 51 of the program managers responded to the questionnaire: a response rate of 36%. To

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increase the response rate, two email reminders were sent to all program managers at 1 week and 2 weeks after the initial invitation.

2.2 Survey development

A self-report web-based questionnaire was designed to assess SPH program managers’ experiences with adverse events associated with safe patient handling. The questionnaire content was based on the expertise of two of the authors who were doctoral prepared nurses and members of the Regional VA Patient Safety Center of Inquiry. The measure addressed two patient injury categories: skin-related adverse events and fall-related adverse events. In addition

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to the closed ended items, the survey asked participants open-ended questions regarding factors related to skin-related and fall-related adverse events at their medical centers.

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The survey consisted of 36 closed-ended questions on skin-related and fall-related adverse

patient events, their causes, prevention, and barriers to prevention. Responses were categorized

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as ranges of number incidents occurring at the medical center in the previous year. In addition,

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12 open-ended questions asked about related factors and how VA medical centers could help prevent adverse events. Specifically, participants were asked “What organizational, equipment,

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patient or provider factors were related to adverse events? What are the most important things staff do to prevent adverse events? What gets in the way of staff preventing adverse events?”

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The survey was pilot tested with two program managers and refined based on their feedback.

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All surveys were delivered through a web-based application, accessed through the specific survey URL, and logged on the commercial web-based survey site. Data were accessible only to

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the project staff through password protected login. VA Nurses who were program managers for the national VA Safe Patient Handling Program completed the online questionnaire between November and December, 2011. A sub-sample of program managers participated in a photonarrative nested component, reported elsewhere (Rugs et al, 2012), providing pictures and describing issues related to lifting equipment.

2.3 Ethical considerations

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The study was approved by the VAMC Research and Development Committee for the quality improvement project at the home facility where the study was conducted. 2. Data analysis

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The quantitative data were analyzed using descriptive statistics, and open-ended responses were coded using thematic analysis. The quantitative analysis used frequencies, means and standard

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deviations to describe the frequency of patient adverse events. The thematic analysis used

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inductive coding to reveal the nature of adverse patient event experiences that VA program managers had at VAMCs. Using an inductive approach we identified recurrent patterns in the

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qualitative data, coded and organized these into categories and ultimately into higher level themes. Three team members met on a weekly basis to code the participant comments for

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emerging themes; this ensured consistency and validity of the coding process. We discussed

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findings with 7 participants to establish credibility (Lincoln and Guba, 1985).

4.1 Quantitative findings

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4.1.1 Survey response

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3. Results

The survey response rate was 36% (n=51 program managers). The majority of the survey was completed entirely with a few missing responses in the demographics. These cases were retained to preserve the sample size and include completed responses in the analysis. Differences in the reported numbers of participant responses are accounted for by these missing responses being excluded from the analysis.

4.1.2 Survey sample characteristics

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Demographic characteristics of the sample are presented in Table 1. The VA SPH program managers who completed the on-line questionnaire were, on average, 52 years old (SD= 8 years;

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range 29-65 years old), 72% Caucasian, and 86% female. Forty-nine percent reported having college degrees and 49% reported having post-graduate degrees. Participants self-identified their

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employment in the VA as on average for 12 years (SD= 7 years), with an average of 3 years

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(SD= 1.3 years) of experience with the SPH program.

-----------------Table 1 about here-------------

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4.1.3 Adverse patient events

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Descriptive statistics of adverse patient events are presented in Tables 2 and 3. VA SPH program

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managers reported their experiences with both skin-related and fall-related patient events

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associated with SPH equipment. The majority of participants reported that no adverse patient

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events associated with patient handling equipment had occurred in the prior year.

Among skin-related adverse events noted by participants, superficial abrasions were the most frequent (46%), followed by contusions (27%), stage 1 and 2 pressure ulcers (9%) and finally, lacerations (7%).

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Among fall-related adverse events noted by program managers, sprains and strains were most frequent (25%), followed by compound fractures (9%), simple fractures (7%), concussions (7%), intracranial bleeding (4%), and uncontrolled bleeding (2%).

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------------------Table 3 about here----------------4.2 Qualitative findings

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4.2.1 Open-ended item response

To explore the nature of patient adverse events associated with SPH in the VA, we analyzed the

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open-ended responses provided by the 98% (n=50) of program managers who completed the

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surveys.

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In qualitative research, saturation of data is achieved based on the depth and breadth of information obtained from participants related to the phenomena under study, not on sample size

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(Corbin and Strauss, 2007; Patton, 1990). Evidence indicates that a sample of 20-60

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knowledgeable people is sufficient to identify and understand key themes in a study of lived

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experience (Bernard and Ryan, 2009). For example, by the 20th case, it is possible little or no new information may be gained (Morgan et al, 2001). Another study that collected sixty (60) in-

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depth interviews found that saturation occurred within the first twelve interviews, and metathemes were identified after analyzing only six interviews (Guest et al, 2006).

4.2.2 Organizational factors related to adverse patient events

Organizational factors involved in patient adverse events included management support, organizational culture, limited resources (including human and equipment), and communication. Program managers focused on inadequate human and equipment resources and safety culture factors. The most common issues mentioned were 1) short staffing; 2) lack of support from

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managers and leaders; 3) equipment unavailability; and 4) lack of proper training and education on the use of equipment. These organizational concerns raised by participants were perceived as inhibiting the ability of staff to appropriately integrate the new SPH practices and prevent

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adverse patient events. One manager said “Not enough facilities management support in maintaining equipment. Too many equipment issues for number of hours of facilities

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management staff provided. Also, staff must trust that the equipment is going to work in order to

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sustain the culture change. Budget constraints limit the amount of support staff available to provide Safe Patient Handling care, which makes it very difficult for unit peer leaders to have

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time to educate and give in-services” (participant identification number #20). Another added,

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“Not having enough, or even having any equipment in some areas or the equipment is outdated

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and difficult to use.”(#31)

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Program managers noted a lack of support for the program by managers and leaders, reflecting the absence of the culture change that was critical to successful implementation of SPH

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programs. The lack of support appeared on different levels, from front-line nurse managers to facility leadership. One program manager commented, “We have policy and equipment/supplies in place since 2008 and plenty of trainings but some folks have not adopted the use of the SPH equipment into their practice.” (#46)

One way organizational factors affect staff is through training on the proper use of SPH equipment. Many program managers mentioned that nurses were often not permitted to leave the unit to attend training due to a lack of support by nurse managers and short staffing situations. Others noted the lack of adequate training, for example in the use of a specific type of

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equipment: “Lack of support by front line Nurse Managers and lack of availability for unit peer leaders to be released for meetings and training” (#30) and “time and staffing shortage leads to

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lack of staff training on proper patient assessments and or algorithms.” (#17)

4.2.3 Human factors related to adverse patient events:

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Human factors associated with adverse patient events included lack of knowledge and skills,

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failure to adhere to clinical guidelines, and patient ability to participate in care. When program managers were asked to describe human factors related to fall- and skin-related adverse events,

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they mentioned 1) improper choice of equipment; 2) staff’s failure to properly assess the patient

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assistive equipment; and 4) patient factors.

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prior to using the equipment; 3) staff non-compliance with the SPH protocol, program and use of

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Program managers noted staff non-compliance with appropriate clinical assessment and equipment and failure to properly perform safe patient handling procedures: “Staff not using the

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equipment as frequently as they should and thinking that it is quicker to manually perform tasks” (#33) and “not following policy as it relates to checking equipment prior to use.”(#33)

Program managers felt that a primary barrier to preventing patient falls was staff confusion about choosing the proper piece of equipment for a specific patient handling task. Misjudgment was associated with a lack of assessment of the patient’s condition immediately prior to selecting the equipment. Timing of the assessment was important because patient status could change frequently. Comments included these: “The provider can misjudge when and what type of equipment should be used in a particular situation depending on patient condition.” (#14) And

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“staff not using proper equipment for moving patient as a result of not conducting continuous patient assessment.” (#42) Lack of communication or difficulty in communicating with cognitively impaired patients was

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seen as a barrier to preventing adverse events. Misunderstanding due to poor communication placed both patients and staff at risk when performing SPH tasks. As one facility champion

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noted, “In one instance a confused patient lifting both legs while in a sit-stand device. Luckily,

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no injury occurred, but staff did not use the proper algorithm as indicated.”(#32)

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Program managers reported that staff did not follow clinical practice guidelines for proper use of equipment, resulting in adverse events or close calls. While skin-related adverse events were

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more common than patient falls, program managers reported more fall- related close calls.

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Examples of fall-related adverse events were noted in the following comments from program

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managers: “…patient was asked to lean forward for sling removal while seated; and patient had no upper body control and leaned forward, ended on the floor. The caregiver was behind the

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patient trying to remove the sling”(#11) and a “patient became weak and let go of the sit to stand lift and slid down and fractured arm.”(#5) Examples of fall-related close calls were noted in the following comments: “One ceiling lift malfunctioned and suspended patient in air. No injury occurred.” (#12) and “One instance of an employee using 2 slings together created a slippery surface in which a patient nearly fell out of the slings.” (#40)

4.2.4 Technological equipment factors related to adverse patient events: Technology factors associated with adverse patient events included equipment reliability and safety features. When program managers were asked to describe equipment factors related to skin-related adverse events, their responses focused on 1) sling texture, 2) ceiling lift batteries 15 Page 15 of 40

not properly recharging, and 3) lack of self-locking brakes. One program manager noted that sling texture can create unwanted friction, especially on fragile skin, causing abrasions or causing a patient to slip. When slings were left under patients, either while in bed or sitting in a

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wheelchair, poor circulation and pressure ulcers could result. One manager pointed out that,

“abrasions noted to a veteran related to the texture of the sling due to his frail condition and it

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being left under him for a prolonged period.”(#30)

Several program managers noted that equipment reliability was a big concern because staff could

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lose faith and stop using the equipment: “Equipment reliability is a big factor and the battery charging is the biggest problem because staff can lose faith that the equipment will work if the

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battery charge runs out. Ceiling lifts are especially problematic…both charging and reliability of

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the holder bar affect staff willingness to use the ceiling lift. If equipment is not used, staff reverts

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to manual lifting which increases the probability of skin breakdown or damage.” (#20)

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A lack of safety features on selected equipment could also put patients and staff at risk. One manager said, “falls can occur with unlocked wheelchairs, beds, and over-bed tables when patients rise up without assistance and the device moves because it is not self-locking and nurses can be injured helping.”(#16)

4.2.5 Preventing adverse patient events:

Program managers felt that developing plans for prevention and using interpersonal communication skills and patient assessment skills would prevent adverse events. They thought it was particularly important to communicate with the wound care team in planning care and 16 Page 16 of 40

with the patient when using the SPH equipment. One said, “Adverse events are easily reduced or eliminated through clear communication and a plan of prevention for the patient.”(#38) To prevent adverse events, program managers recommended that 1) staff follow established SPH

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protocols for equipment use and patient assessment; and 2) leadership support SPH activities, including ensuring access to proper SPH training. Comments included these:

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“Working as a team, using extra sets of eyes to make sure all SPH activities are done correctly

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and that the procedure is stopped for any concern before going on.” (#16) And “Education and training; Leadership support and providing information through the appropriate channels for the

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wound care team - the current information they are receiving does not include the use of SPH

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equipment.”(#39)

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A principal barrier to preventing skin-related adverse events reported by program managers was

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staffing issues (staff being in a hurry and not having adequate training). One of the major issues was training staff to select and administer the proper equipment, which was in turn related to

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sufficient resources. The following quote illustrates this point: “Lack of resources; be it time, equipment, education, or staff. If staff members’ do not have the equipment they need they fail. If they do not have the training they can't use the equipment. If they don't have the time because of lack of staff or lack of ease of use of equipment they fail.” Finally, just having a team approach and a unit culture to be proactive helps staff play a major role in patient outcomes.” (#38) 4.2.6 Recommendations for increasing patient safety

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Specific program managers’ suggestions for enhancing patient safety in SPH programs are listed in Table 4.

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--------------------Table 4 about here----------------

5. Discussion

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5.1 Adverse patient events in safe patient handling

This is the first study to identify patient adverse events, related contextual factors, and

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recommendations for prevention associated with safe patient handling programs in a large national healthcare system in the United States. Safe patient handling has been identified as a

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means of preventing injuries in nursing staff and our findings indicate that these program

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managers are aware of adverse patient events associated with these programs. While the majority

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of participants reported no adverse patient events associated with their patient handling programs, other participants did report skin related injuries, ranging from abrasions to pressure

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ulcers, and fall related injuries, ranging from sprains to fractures and intracranial bleeding. This supports previous patient safety research that highlighted fall-related incidents, associated with patient handling and movement (Cornish and Jones, 2012) and adds information on skin injuries.

Although the prevalence rate of adverse patient events associated with safe patient handling programs is unknown, based on these findings, some patients are being injured. This patient safety concern can be reversed to make safe patient handling safe for both nursing staff and patients if barriers to safety and preventive approaches can be disseminated. In addition to more research on preventing adverse patient events, research focused on three problems concurrently

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(patient safety, safe patient handling, and falls prevention) is needed to provide a foundation for practice using technological equipment.

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5.2 Factors related to adverse patient events

Participants described the contextual factors related to adverse events and made suggestions for

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preventing adverse events. Contextual factors focused on organizational factors, human factors,

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and technological equipment factors.

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Program managers who identified important things staff could do to prevent adverse events focused on nursing practice changes necessitated by the integration of new technological

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equipment into patient handling and movement. Program managers reported activities such as 1)

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changing the conduct of nursing assessments of patient functional status to occur immediately

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prior to transfers, 2) developing prevention plans to include identifying patients at risk for falls, and 3) using slings to temporarily relieve pressure from bony prominences resulting in

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prevention of skin injuries.

Program managers who identified barriers to prevention of adverse events focused on lack of resources, coordination across departments, and full and accurate patient assessments. Program managers described: 1) a lack of staff, equipment, and training, 2) inaccessible equipment, 3) the need for staff to work more closely with the skin care team, and 4) failure to fully and accurately assess patient mobility and ability to participate in care. This study supports previous research on safety and human factors research that indicates patient safety problems are associated with nurse workloads (Lang et al, 2004).

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5.3 Research Implications

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This study provided a unique contribution by identifying adverse patient events associated with a patient handling program, related contextual factors, and recommendations for prevention as

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perceived by program managers in a large national healthcare system. Although we cannot

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identify how frequently adverse patient events associated with SPH occurred in VA medical centers, it is clear that program managers’ believe that when they did occur, they may have been

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prevented. While the survey was designed for use in the VA healthcare system, it could be

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barriers to prevention in any country.

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adapted to explore contextual factors related to adverse patient events, prevention methods, and

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We can place the categories identified in this study within a human factors model (Institute of Medicine, 2000; Weinger et al, 1998). For example, we can conceptualize the time limits and

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competing priorities in the contextual environment, the workloads and staff training needs as human factors, and the patient handling equipment as new technology. Future studies may consider applying human factors in the study of adverse patient events in safe patient handling, specifically focusing on system conditions and challenges of integrating technologies that may pose risks to patient safety (Powell-Cope et al, 2008).

5.4 Policy Implications

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Arguably the most important barrier to safe patient handling is a lack of knowledge about the incidence of adverse patient events. A tracking, reporting and dissemination system is essential. One study described the incidence rate in the UK and authors emphasized the need for accurate

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methods to track patient handling and movement related to clinical incidence (Cornish and Jones, 2012). Statistical data collection and monitoring on patient handling and movement injuries

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should be a priority for administrators, professional organizations, and policymakers to enhance

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patient safety in handling and movement while maintaining staff safety.

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5.5 Practice Implications

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Clearly, nurse program managers and administrators must address practice changes to prevent

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adverse patient events related to SPH. These program managers reported that nursing staff could

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prevent adverse patient events by following comprehensive clinical guidelines and algorithms, conducting frequent patient assessments, identifying risks, communicating, and educating.

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However, they also noted a lack of resources such as staff, readily available equipment, and necessary training to prevention. Program managers also highlighted the importance of accurate nursing assessments of patient mobility and fall risk and collaboration with skin care teams to prevent adverse events.

These findings are consistent with the literature which suggests that lifting and moving patients with patient handling equipment should be considered a high risk process (deRuiter and Liaschenko, 2011) with the potential to introduce new errors, including adverse patient events (Battles and Reyes, 2002; Hignett and Griffiths, 2009; Nelson et al., 2003). Participants in the

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current study suggested that safe use of these new technologies depends upon professional nursing assessments and interventions. Clinical assessments of patients are needed to inform the selection of equipment in specific patient handling and movement situations, and the literature

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suggests that specific nursing skills and expertise are required for this role (Ali and Glenister,

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2001; Cornish and Jones, 2010; Schoenfisch et al., 2011).

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In some cases, professional nursing assessments may indicate that use of the new lifting and movement equipment could pose a risk to patients (deRuiter and Liaschenko, 2011). Consistent

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with the current study findings, adverse events associated with use of patient handling equipment have previously been attributed to: (1) incorrect selection of patient handling equipment, (2)

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failure to accurately assess the patient, (3) damaged or malfunctioning slings or lifts, (4)

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inadequate training, and (5) incompatibility of sling and lift equipment (Ali and Glenister, 2001;

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Cornish and Jones, 2010; Cornish and Jones, 2012).

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After a patient functional assessment has been conducted, the nurse must use established algorithms to analyze and select the appropriate patient handling and movement equipment (Ali and Glenister, 2001). The patient handling equipment requires integration of equipment considerations into patient care plans and the clinical practice of the nursing staff. For example, nursing staff need to conduct careful equipment checks to assure safe operating conditions and appropriate equipment availability (Cornish and Jones, 2010). A related issue for organizational leadership is consideration of the physical environment. Specifically, organizations need to assure appropriate physical storage space and location of items within easy reach for use by staff in patient rooms (Schoenfisch et al., 2011).

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Most adverse events are multifactorial, resulting from an overlap of organizational system and human errors. Some adverse events may be unanticipated, due to changing technologies.

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According to Attarian, “Preventable or avoidable adverse events are a direct result of failure(s) to follow recognized, evidence-based best practices or guidelines at the individual and/or system

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level” (Attarian, 2012 p.1). Organizational system issues—such as poor management decisions,

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dysfunctional corporate cultures, poor communications, inadequate resources, poor staffing, poor documentation, or a lack of safeguards—generally facilitate human errors. Individual human

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errors may be knowledge-based, skill-based, or fatigue-based, or may result from failure to

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healthcare organization (Attarian, 2012).

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follow rules, technical mistakes, and/or inability to cope with the complexities or demands of the

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This qualitative analysis informs us about the factors related to adverse events in SPH and suggests implications for how healthcare providers should work with patients and other providers

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during assessment, intervention and follow-up care. An array of clinical resources are available to facilities planning to implement SPH practices and equipment. Tailoring various clinical resources to individual needs may facilitate the safe use of SPH equipment.

5.6 Educational Implications

Because use and equipment factors overlap and affect each other, each decision process must be considered in the context of the whole. It is important for healthcare providers to have ongoing communications with patients and other providers to explore patient status and preferences and

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how they may change over time. Assessment forms and decision algorithms used in clinical settings also need to be assessed in light of the current findings, to identify strengths and limitations of current tools and training materials. The findings of this project could form the

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to help them monitor their SPH activities and prevent adverse events.

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basis of a provider-oriented guide to educate healthcare providers about various aspects of SPH,

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5.7 Limitations of the data

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Program manager recollections of adverse patient events may be less dependable than a safety events record, however safety records may not specify the relation to patient handling equipment

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or other related factors. A response rate of 36%, a lack of information on non-responders and

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their medical center settings, and the possibility that non-responders were those experiencing

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more frequent adverse patient events also raise issues of selection bias and representativeness of the findings. Further, these findings represent experiences in anonymous VA academic medical

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centers, limiting our ability to confirm regional representation and compare regional variations. However, the medical centers responding represented over one third of centers nationwide, and common policies and processes are inherent in these organizations suggesting that the findings provide insights into potential issues that warrant exploration at other medical centers.

6. Conclusions

While these program managers reported both skin- and fall- related adverse patient events, the frequency of these events was relatively low and the severity of the injuries to patients was low.

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Nevertheless, the findings provide compelling evidence of the potential for patient health and safety risk and the need to prevent the potential risk to patients and organizations. Safe use of patient lift equipment in the nationwide VA SPH program requires skilled

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identification, vigilance, and planning to prevent adverse patient events. This project provides

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important information for subsequent SPH program development and implementation.

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The nursing profession must develop prevention and safety approaches commensurate with the integration of new technologies in direct patient handling and movement. Nurses must also

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collaborate with other disciplines and across levels of their organizations to create a culture of safety and prevention that is reflected in the support of stakeholders at all levels and sufficient

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equipment, training, policies, protocols, and staffing levels. While professional nursing

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communication and assessments are needed to make appropriate selections of equipment for use

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in handling and moving patients, it is also important to recognize the complex factors that are included in the decision to use the equipment. As deRuiter (2008) notes, the clinician must

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balance various policies and procedures, the realities of the available equipment and staff, the patient condition and the potential risks inherent in each of these.

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Conflict of Interest Authors declare no conflicts of interest exist.

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Funding

This material is the result of work supported by the Veterans Integrated Service Network Region

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8 Patient Safety Center and the National Patient Safety Center, and use of facilities at the James

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A. Haley Veteran’s Affairs Hospital, Tampa, FL.

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Contents do not represent the views of the sponsor, the Department of Veterans Affairs nor the US Government. Sponsors had no involvement in study design; in the collection, analysis and

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Acknowledgements

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interpretation of data; in writing the report; or in the decision to submit the paper for publication.

Our sincerest thanks to the Safe Patient Handling program managers in VA medical centers for

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their participation in this quality improvement project.

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2. Alamgir, H., Yu, S., Fast, C., Hennessy, S., Kidd, C., Yassi, A., 2008. Efficiency of overhead ceiling lifts in reducing musculoskeletal injury among carers working in long-term care

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institutions. Injury 39 (5), 570-577.

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3. Attarian, D.E., 2012. What is a preventable adverse event? Current trends forecast double jeopardy for physicians and hospitals. American Academy of Orthopaedic Surgeons 6 (7).

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(accessed 2/20/2014)http://www.aaos.org/news/aaosnow/may08/managing6.asp . 4. Baptiste, A., McCleerey, M., Matz, M., Evitt, C.P., 2008. Proper sling selection and application

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while using patient lifts. Rehabilitation Nursing 33 (1), 22-32.

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5. Battles, J.B., Reyes, M.A., 2002. Technology and patient safety: A two-edged sword.

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Biomedical Instrument Technology 36 (2), 84-88. 6. Bernard, H.R., Ryan, G.W., 2009. Analyzing qualitative data: systematic approaches. Sage

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Publications, Inc., Thousand Oaks, CA.

7. Corbin, J., Strauss, A., 2007. Basics of qualitative research: techniques and procedures for developing grounded theory. 3rd ed. Sage Publications, Inc, Thousand Oaks, CA. 8. Cornish, J., Jones, A., 2010. Factors affecting compliance with moving and handling policy: Student nurses’ views and experiences. Nursing Education in Practice 10, 96-100. 9. Cornish, J., Jones, A., 2012. Moving and handling and patient safety: analysis of clinical incidents. British Journal of Nursing 21 (3), 166-70. 10. de Ruiter, H.P., 2006. Viewpoint: Lifting devices revisited: safer for nurses- but what about the patients? American Journal of Nursing 106 (9), 13.

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11. deRuiter, H.P., Liaschenko, J., 2011. To lift or not to lift: patient handling practices. American Association of Occupational Health Nursing Journal 59 (8), 337-43. 12. de Ruiter, H.P., 2008. To lift or not to lift: an institutional ethnography of patient handling

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practices. A dissertation submitted to the faculty of the graduate school of the university of Minnesota.

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13. FDA US Food and Drug Administration a (2011). Manufacturer and user facility device

http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Results.cfm?RequestTimeout=50

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14. FDA US Food and Drug Administration b (2011). Manufacturer and user facility device

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http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Results.cfm?RequestTimeout=50

15. FDA US Food and Drug Administration c (2011). Manufacturer and user facility device

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experience (MAUDE) database (accessed July 19, 2011) http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/detail.cfm?mdrfoi__id=21394 52

16. FDA US Food and Drug Administration c (2011). Manufacturer and user facility device experience (MAUDE) database (accessed August 17, 2011) http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Results.cfm?RequestTimeout= 500 17. FDA US Food and Drug Administration c (2011). Manufacturer and user facility device experience (MAUDE) database (accessed August 17, 2011)

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http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Results.cfm?RequestTimeout= 500 18. FDA US Food and Drug Administration c (2011). Manufacturer and user facility device

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experience (MAUDE) database (accessed August 17, 2011)

http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/detail.cfm?mdrfoi__id=20850

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19. Green, S.A., 2001. The evolution of medical technology: lessons from the Burgess Shale. Clinical Orthopaedics and Related Research 385, 260-6.

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20. Guest, G., Bunce, A., Johnson, L., 2006. How many interviews are enough? An experiment with data saturation and variability. Field Methods 18 (1), 59–82.

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21. Hignett, S., Griffiths, P., 2009. Manual handling risks in the bariatric (obese) patient pathway

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in acute sector, community and ambulance care and treatment. Work 33 (2), 175-80.

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22. Institute of Medicine, 2000. To err is human: building a safe health system. Committee on quality of healthcare in America. National Academy Press, Washington, D.C.

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23. Klein, G., 1998. Sources of power: how people make decisions. The MIT Press, Cambridge, MA.

24. Koppelaar, E., Knibbe, J.J., Miedema, H.S., Burdorf, A., 2009. Determinants of implementation of primary preventive interventions on patient handling in healthcare: A systematic review. Occupational and Environmental Medicine 66 (6), 353-360. 25. Lang, T.A., Hodge, M., Olson, V., Romano, P.S., Kravitz, R.L., 2004. Nurse-patient ratios: a systematic review on the effects of nurse staffing on patient, nurse employee, and hospital outcomes. Journal of Nursing Administration 34 (7–8), 326–37. 26. Lincoln, Y.S., Guba, E.G., 1985. Naturalistic Inquiry. Sage, Beverly Hills, CA.

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27. Morgan, M.G., Fischhoff, B., Bostrom, A., Atman, C.J., 2001 Risk communication: a mental models approach. Cambridge University Press, Cambridge, England. 28. Nelson, A., Lloyd, J., Menzel, N., Gross, C., 2003. Preventing nursing back injuries:

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redesigning patient handling tasks. American Association of Health Nurses Journal 51 (3), 126-34.

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29. Nelson, A., Motacki, K., Menzel, N., 2009. The illustrated guide to safe patient handling and

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movement. Springer Publishing Company, New York.

30. Patton, M.Q., 1990. Qualitative research & evaluation methods. 3rd ed. Sage Publications,

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Inc., Thousand Oaks, CA.

31. Powell-Cope, G., Nelson, A.L., Patterson, E.S., 2008. Patient care technology and safety. In

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R. Hughes (Ed.), Patient safety & quality - an evidence-based handbook for nurses. AHRQ.

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(accessed March 20, 2014) http://www.ahrq.gov/qual/nurseshdbk/

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32. Rugs, D., Elnitsky C., Lind, J., Powell-Cope, G., 2012. Mitigating adverse events with patient handling equipment: A photo-narrative project. American Journal of Safe Patient

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Handling & Movement 2, 112-118.

33. Schoenfisch, A.L., Myers, D.J., Pompeii, L.A., Lipscomb, H.J., 2011. Implementation and adoption of mechanical patient lift equipment in the hospital setting: The importance of organizational and cultural factors. American Journal of Industrial Medicine 54 (12), 94654.

34. U.S. Department of Labor, 2013 Occupational safety & health administration, we can help. Safety and health topics- safe patient handling. (accessed March 2, 2014) https://www.osha.gov/SLTC/healthcarefacilities/safepatienthandling.html

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35. Weinger, M.B., Pantiskas, C., Wiklund, M., Carstensen, P., 1998. Incorporating human factors into the design of medical devices. JAMA 280 (17), 1484. 36. Wright, L.R., Evitt, C.P., Baptiste, A., 2005. Protocol for safe use of patient handling

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slings-does one size fit all? Association of Occupational Health Professionals Journal Fall,

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28-35.

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Male

6 36

14.3 85.7

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Female

Percent

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Table 1. Demographic Characteristics of SPH Program Managers Variables N= 51 Gender

Age

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Mean (SD) Years

52 (8)

Range 29-65 Years

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Years of education

1

2.3

21

48.8

21

48.8

American Indian or Alaskan Native

1

2.3

Asian or Pacific Islander

2

4.6

Black

6

13.9

White

31

72.1

Other

3

6.9

35

79.5

9

20.4

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Trade/some college College Graduate

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Post Graduate degree

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Race/ethnicity

Discipline

Nursing professions Unit Employment at VA in years Mean (SD)

12 (7.1)

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Range 1-25 Experience in VHA SPH program in years Mean (SD) 3 (1.3)

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Range 1-7

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Note Items may not add to total sample size as participants did not to respond to selected demographic characteristics

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Table 2. Skin-related Injuries Associated with SPH Equipment in the Last Year Variables N= 51 Percent Contusions 35

rarely (=1 or 2)

14 0

28.6 0

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occasionally (=3 or 4)

71.4

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never (=0)

0

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very Frequently (more than 7) Superficial Abrasions

26

54.2

18

37.5

4

8.3

0

0

43

93.5

3

6.5

occasionally (=3 or 4)

0

0

very Frequently (more than 7)

0

0

43

91.5

rarely (=1 or 2)

3

6.4

occasionally (=3 or 4)

1

2.1

very Frequently (more than 7)

0

0

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never (=0)

0

rarely (=1 or 2)

never (=0)

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rarely (=1 or 2)

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Lacerations

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very Frequently (more than 7)

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occasionally (=3 or 4)

Stage 1 and 2 Pressure Ulcers never (=0)

Deep Tissue Pressure Ulcers

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100

rarely (=1 or 2)

0

0

occasionally (=3 or 4)

0

0

very Frequently (more than 7)

0

0

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46

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never (=0)

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Table 3. Fall-related Injuries Associated with SPH Equipment in the Last Year Variables N= 51 Percent Sprains and Strains 76.5

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34

rarely (=1 or 2)

7

occasionally (=3 or 4)

4

very Frequently (more than 7)

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never (=0)

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0

Simple Factures

8.9

0

42

93.3

2

4.4

1

2.2

0

0

42

91.3

4

8.7

occasionally (=3 or 4)

0

0

very Frequently (more than 7)

0

0

42

93.3

rarely (=1 or 2)

3

6.7

occasionally (=3 or 4)

0

0

very Frequently (more than 7)

0

0

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never (=0)

15.6

rarely (=1 or 2)

never (=0)

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rarely (=1 or 2)

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Major Fractures

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very Frequently (more than 7)

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occasionally (=3 or 4)

Concussions

never (=0)

Intracranial Bleed

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43

95.6

rarely (=1 or 2)

2

4.4

occasionally (=3 or 4)

0

0

very Frequently (more than 7)

0

0

Other Uncontrolled Bleeding 44 1

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rarely (=1 or 2) occasionally (=3 or 4)

2.2

0

0

0

0

44

100

0

0

0

0

0

0

44

100

rarely (=1 or 2)

0

0

occasionally (=3 or 4)

0

0

very Frequently (more than 7)

0

0

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very Frequently (more than 7) Strangulation or Suffocation

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never (=0)

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occasionally (=3 or 4)

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rarely (=1 or 2)

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very Frequently (more than 7) Death

97.8

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never (=0)

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never (=0)

never (=0)

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Table 4: Recommendations for Increasing Patient Safety

Solutions/ next steps

Nursing Assessments

 Assure appropriate professional nurse assessments of patients as

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Factor

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conditions change to identify which equipment may be used.

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 Collaborate with senior leadership and national experts to review and revise safe patient handling and movement provider algorithms

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and policies.

 Assess patient ability to follow instructions for equipment use.  Undertake organizational and building refinements as needed to

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Equipment at Site of Care

 Train, retrain and assess competency of users.

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New Equipment Technology

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provide easy access to equipment for use in patient rooms.

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 Determine most appropriate equipment for patient population and refine the equipment and materials needed at each location or unit.

 Assure compatibility, usable condition, and safety of slings with transfer devices and patient condition.

Prevention & Communication

 Enhance users’ vigilance by increasing awareness of types and causes of adverse events.  Assure resource availability, management support.  Assure staffing formula considers high acuity and high fall risk and need for professional nursing assessment of patient for appropriate

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equipment selection.  Provide patient and family information and autonomy in choice of

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the equipment used.  Demonstrate the equipment to the patient before use to support

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patient participation.

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What is already known about the topic?  Evidence emerging from the United Kingdom suggests patient care issues associated with patient handling and movement may compromise patient safety.

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 Factors related to patient injury during patient handling and movement include patient

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cooperation, user training, device wear and tear, and suitability and correct operation of equipment.

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What this paper adds?

 This study adds to the international literature by identifying adverse patient events

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associated with a patient handling program, related contextual factors, and

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recommendations for prevention as perceived by program managers in the largest national healthcare system in the United States.

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 This study provides quantitative and qualitative evidence that suggests preventable

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patient adverse events may result from organizational and human use factors.  Program managers’ recommendations for preventing adverse events include frequent

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nursing assessments, maintaining equipment at the site of care, and assuring staffing formulas include acuity level, high fall risk and frequent nursing assessments.

40 Page 40 of 40

Implications for patient safety in the use of safe patient handling equipment: a national survey.

The prevalence of musculoskeletal injuries among nursing staff has been high due to patient handling and movement. Internationally, healthcare organiz...
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