Access the full text.
Sign up today, get DeepDyve free for 14 days.
M. Rothberg, I. Abraham, P. Lindenauer, D. Rose (2005)
Improving Nurse-to-Patient Staffing Ratios as a Cost-Effective Safety InterventionMedical Care, 43
J. Rhymes, R. Jaeger (1988)
Falls. Prevention and management in the institutional setting.Clinics in geriatric medicine, 4 3
N. Cowan (2001)
The magical number 4 in short-term memory: A reconsideration of mental storage capacityBehavioral and Brain Sciences, 24
Melissa Krauss, Nhial Tutlam, Eileen Costantinou, Shirley Johnson, D. Jackson, V. Fraser (2008)
Intervention to Prevent Falls on the Medical Service in a Teaching HospitalInfection Control & Hospital Epidemiology, 29
Michael VIDULlCH (1991)
Using the Subjective Workload Dominance (SWORD) Technique for Projective Workload AssessmentHuman Factors: The Journal of Human Factors and Ergonomics Society, 33
P. O’Connor, Joan Creager, Sharon Mooney, A. Laizner, J. Ritchie (2006)
Taking aim at fall injury adverse events: best practices and organizational change.Healthcare quarterly, 9 Spec No
J. Fiesta (1998)
Liability for falls.Nursing management, 29 3
S. Devandry, J. Cooper (2009)
Mandating Nurse Staffing in Pennsylvania: More than a Numbers GameJONA: The Journal of Nursing Administration, 39
K. Shojania, B. Duncan, K. McDonald, R. Wachter, A. Markowitz (2001)
Making health care safer: a critical analysis of patient safety practices.Evidence report/technology assessment, 43
Patricia Johnson, Lisa Thornhill (2006)
Noise Reduction in the Hospital SettingJournal of Nursing Care Quality, 21
L. Leape (2009)
Errors in medicine.Clinica chimica acta; international journal of clinical chemistry, 404 1
Daniel Sterling, J. O'Connor, J. Bonadies (1998)
Geriatric falls: injury severity is high and disproportionate to mechanism.The Journal of trauma, 50 1
P. Carayon, K. Schultz, A. Hundt (2004)
Righting wrong site surgery.Joint Commission journal on quality and safety, 30 7
J. Temple, J. Warm, W. Dember, Keith Jones, Constance LaGrange, G. Matthews (2000)
The Effects of Signal Salience and Caffeine on Performance, Workload, and Stress in an Abbreviated Vigilance TaskHuman Factors: The Journal of Human Factors and Ergonomics Society, 42
L. Wolf, P. Potter, Jennifer Sledge, S. Boxerman, D. Grayson, B. Evanoff (2006)
Describing Nurses' Work: Combining Quantitative and Qualitative AnalysisHuman Factors: The Journal of Human Factors and Ergonomics Society, 48
A. Delacrétaz, P. Frutiger (1994)
Nursing summary and experienced workload.Computer methods and programs in biomedicine, 43 3-4
D. Bates, K. Pruess, P. Souney, R. Platt (1995)
Serious falls in hospitalized patients: correlates and resource utilization.The American journal of medicine, 99 2
M. Rogers, R. Cook, R. Bower, M. Molloy, M. Render (2003)
Barriers to Implementing Wrong Site Surgery Guidelines: A Cognitive Work AnalysisProceedings of the Human Factors and Ergonomics Society Annual Meeting, 47
M. Blegen, C. Goode, L. Reed (1998)
Nurse staffing and patient outcomes.Nursing research, 47 1
Giggi Udén, M. Ehnfors, Kerstin Sjöström (1999)
Use of initial risk assessment and recording as the main nursing intervention in identifying risk of falls.Journal of advanced nursing, 29 1
G. Yates, D. Bernd, Shannon Sayles, C. Stockmeier, Gene Burke, Gregory Merti (2005)
Building and sustaining a systemwide culture of safety.Joint Commission journal on quality and patient safety, 31 12
B. Mark, L. Hughes, M. Belyea, Cynthia Bacon, Yunkyung Chang, Cheryl Jones (2008)
Exploring Organizational Context and Structure as Predictors of Medication Errors and Patient FallsJournal of Patient Safety, 4
N. Dunton, B. Gajewski, R. Taunton, Jan Moore (2004)
Nurse staffing and patient falls on acute care hospital units.Nursing outlook, 52 1
A. Minnick, L. Mion (2009)
Nurse Labor Data: The Collection and Interpretation of Nurse-to-Patient RatiosJONA: The Journal of Nursing Administration, 39
T. Lang, M. Hodge, Valerie Olson, P. Romano, R. Kravitz (2004)
Nurse–Patient Ratios: A Systematic Review on the Effects of Nurse Staffing on Patient, Nurse Employee, and Hospital OutcomesJONA: The Journal of Nursing Administration, 34
B. Peacock, G. Goebel (2002)
Wrong Number: They Didn't Listen to MillerErgonomics in Design: The Quarterly of Human Factors Applications, 10
Gregg Meyer, N. Foster, S. Christrup, John Eisenberg (2001)
Setting a research agenda for medical errors and patient safety.Health services research, 36 1 Pt 1
Wayne Gray (2000)
The nature and processing of errors in interactive behaviorCogn. Sci., 24
B. Peacock (2002)
Murphy's Law: If It Can Happen, It WillErgonomics in Design: The Quarterly of Human Factors Applications, 10
Timothy Vogus, K. Sutcliffe (2007)
The Safety Organizing Scale: Development and Validation of a Behavioral Measure of Safety Culture in Hospital Nursing UnitsMedical Care, 45
A. Baddeley (1990)
Human Memory: Theory and Practice, Revised Edition
E. Lake, Robyn Cheung (2006)
Are Patient Falls and Pressure Ulcers Sensitive to Nurse Staffing?Western Journal of Nursing Research, 28
J. Effken (2002)
Different lenses, improved outcomes: a new approach to the analysis and design of healthcare information systemsInternational journal of medical informatics, 65 1
Joann Trypuc, A. Hudson, H. Macleod (2006)
Expert panels and ontario's wait time strategy: part 2.Healthcare quarterly, 9 3
J. Rasmussen, A. Pejtersen, L. Goodstein (1994)
Cognitive systems engineering
A. Wall (2000)
Book ReviewTo Err is Human: building a safer health system Kohn L T Corrigan J M Donaldson M S Washington DC USA: Institute of Medicine/National Academy Press ISBN 0 309 06837 1 $34.95British Journal of Healthcare Management, 6
P. Halfon, Y. Eggli, G. Melle, A. Vagnair (2001)
Risk of falls for hospitalized patients: a predictive model based on routinely available data.Journal of clinical epidemiology, 54 12
J. Welton (2008)
Implications of Medicare Reimbursement Changes Related to Inpatient Nursing Care QualityJONA: The Journal of Nursing Administration, 38
Mahbub Rashid (2006)
A Decade of Adult Intensive Care Unit Design: A Study of the Physical Design Features of the Best‐Practice ExamplesCritical Care Nursing Quarterly, 29
David Oliver, A. Hopper, P. Seed (2000)
Do Hospital Fall Prevention Programs Work? A Systematic ReviewJournal of the American Geriatrics Society, 48
Ami Becker, J. Warm, W. Dember, P. Hancock (1995)
Effects of jet engine noise and performance feedback on perceived workload in a monitoring task.The International journal of aviation psychology, 5 1
M. Vassallo, R. Vignaraja, J. Sharma, Helen Hallam, K. Binns, R. Briggs, I. Ross, S. Allen (2004)
The Effect of Changing Practice on Fall Prevention in a Rehabilitative Hospital: The Hospital Injury Prevention StudyJournal of the American Geriatrics Society, 52
K. Hendy, Jianqiao Liao, P. Milgram (1997)
Combining Time and Intensity Effects in Assessing Operator Information-Processing LoadHuman Factors: The Journal of Human Factors and Ergonomics Society, 39
K. Vicente (1999)
Cognitive Work Analysis: Toward Safe, Productive, and Healthy Computer-Based Work
R. Shorr, L. Mion, A. Chandler, Linda Rosenblatt, Debra Lynch, L. Kessler (2008)
Improving the Capture of Fall Events in Hospitals: Combining a Service for Evaluating Inpatient Falls with an Incident Report SystemJournal of the American Geriatrics Society, 56
Donna Alcée (2000)
The experience of a community hospital in quantifying and reducing patient falls.Journal of nursing care quality, 14 3
J. Coffman, J. Seago, J. Spetz (2002)
Minimum nurse-to-patient ratios in acute care hospitals in California.Health affairs, 21 5
R. Koppel, Tosha Wetterneck, J. Telles, B. Karsh (2008)
Technology Evaluation: Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient SafetyJournal of the American Medical Informatics Association : JAMIA, 15 4
Blomkvist, C. Eriksen, T. Theorell, R. Ulrich, G. Rasmanis (2005)
Acoustics and psychosocial environment in intensive coronary careOccupational and Environmental Medicine, 62
K. Perell, A. Nelson, Ronald Goldman, S. Luther, N. Prieto-Lewis, L. Rubenstein (2001)
Fall risk assessment measures: an analytic review.The journals of gerontology. Series A, Biological sciences and medical sciences, 56 12
D. Oliver, F. Daly, F. Martin, M. Mcmurdo (2004)
Risk factors and risk assessment tools for falls in hospital in-patients: a systematic review.Age and ageing, 33 2
Thomas Nygren (1991)
Psychometric Properties of Subjective Workload Measurement Techniques: Implications for Their Use in the Assessment of Perceived Mental WorkloadHuman Factors: The Journal of Human Factors and Ergonomics Society, 33
S. Hart, L. Staveland (1988)
Development of NASA-TLX (Task Load Index): Results of Empirical and Theoretical ResearchAdvances in psychology, 52
D. Ganz, Y. Bao, P. Shekelle, L. Rubenstein (2007)
Will my patient fall?JAMA, 297 1
D. Bertram, D. Opila, Jeffrey Brown, S. Gallagher, R. Schifeling, Irene Snow, C. Hershey (1992)
Measuring Physician Mental Workload: Reliability and Validity Assessment of a Brief InstrumentMedical Care, 30
A. Bonner, N. Castle, Aiju Men, S. Handler (2009)
Certified nursing assistants' perceptions of nursing home patient safety culture: is there a relationship to clinical outcomes?Journal of the American Medical Directors Association, 10 1
G. Loftus, V. Dark, Diane Williams (1979)
Short-Term Memory Factors in Ground Controller/Pilot CommunicationHuman Factors: The Journal of Human Factors and Ergonomics Society, 21
AbstractObjective To identify factors in the nursing work domain that contribute to the problem of inpatient falls, aside from patient risk, using cognitive work analysis.Design A mix of qualitative and quantitative methods were used to identify work constraints imposed on nurses, which may underlie patient falls.Measurements Data collection was done on a neurology unit staffed by 27 registered nurses and utilized field observations, focus groups, time–motion studies and written surveys (AHRQ Hospital Survey on Patient Culture, NASA-TLX, and custom Nursing Knowledge of Fall Prevention Subscale).Results Four major constraints were identified that inhibit nurses' ability to prevent patient falls. All constraints relate to work processes and the physical work environment, opposed to safety culture or nursing knowledge, as currently emphasized. The constraints were: cognitive ‘head data’, temporal workload, inconsistencies in written and verbal transfer of patient data, and limitations in the physical environment. To deal with these constraints, the nurses tend to employ four workarounds: written and mental chunking schemas, bed alarms, informal querying of the previous care nurse, and informal video and audio surveillance. These workarounds reflect systemic design flaws and may only be minimally effective in decreasing risk to patients.Conclusion Cognitive engineering techniques helped identify seemingly hidden constraints in the work domain that impact the problem of patient falls. System redesign strategies aimed at improving work processes and environmental limitations hold promise for decreasing the incidence of falls in inpatient nursing units.
Journal of the American Medical Informatics Association – Oxford University Press
Published: May 1, 2010
Read and print from thousands of top scholarly journals.
Already have an account? Log in
Bookmark this article. You can see your Bookmarks on your DeepDyve Library.
To save an article, log in first, or sign up for a DeepDyve account if you don’t already have one.
Copy and paste the desired citation format or use the link below to download a file formatted for EndNote
Access the full text.
Sign up today, get DeepDyve free for 14 days.
All DeepDyve websites use cookies to improve your online experience. They were placed on your computer when you launched this website. You can change your cookie settings through your browser.