CHAPTER TWELVE

Nursing Sensitive Outcome Indicators

Esther Y H Wong, L S Chau, K Y Yu, Rowlina P W Leung, Peter C K Lai, Joanna W P Lo, S F Lee

LEARNING OUTCOMES (NDNQI). Its goals are to promote and facilitate the standardization
of information submitted by hospitals across the United States on
After completing this chapter you will be able to: nursing quality and patient outcomes. Yang et al. (1999) defined
• Identify the characteristics of nursing sensitive outcome NSOI as:
indicators changes in health status upon which nursing care has had
• Review the definitions of fall, displacement of tubes/lines/drains a direct influence.
and medication incidents The International Council of Nurses (ICN, 2001) stated it is
• Understand the risk factors of falls in intensive care … the measure or status of a nursing diagnosis at points
• Highlight strategies of fall prevention in time after a nursing intervention. Nursing-sensitive
indicators are specific to nursing and differ from medical
• Discuss recommendations for minimizing the chance of
indicators of care quality. As such, nursing outcomes
displacement of tube/line/drains
indicators are those outcomes most influenced by nursing
• Explain the types and causes of medication errors in intensive care (Montalvo, 2007).
care unit
NDNQI began formally collecting data related to ten NSQIs for acute
• Discuss strategies for improving medication safety care settings including:
• Identify evidence-based interventions that are effective in • Total nursing care hours provided per patient day
enhancing patient and family satisfaction
• Mix of RNs, LPNs and unlicensed staff caring for patients in
• Discuss the role of the nurse in promoting improved care in the acute care settings
ICU using nursing sensitive outcome indicators
• Pressure ulcers (terminology in 2015)
INTRODUCTION • Nursing staff satisfaction
• Nosocomial infection rate (bacteremia’s associated with central
The dawn of the twenty-first century marks a new era for the entire lines)
nursing profession. To keep pace with the ageing population; • Patient falls
advanced technology; rising public expectation; escalating
healthcare costs; and the advent of modern medicine; coupled with • Patient satisfaction with overall care
the need to achieve improvement in healthcare quality and safety, • Patient satisfaction with educational information
clinical nurses, and nurse executives are increasingly concerned • Patient satisfaction with pain management
about measuring the outcomes of care in their workplace and
• Patient satisfaction with nursing care.
gathering evidence to justify their decisions for resources allocation.
The growing sophistication of the health care systems everywhere (Nursing Administration Quarterly 2003; Nursing World, ANA
calls for an increased emphasis on evidence and outcomes. Indicator History, 2015)
Gallagher and Rowell (2003) opined that: The recommended definitions of the ten indicators can be found in
The provision of outcome-oriented, cost-effective health ANA’s 2015 publication. In this chapter fall displacement of tubes/
care is no longer a goal. It is a mandate. To accomplish this lines/drains, medication incidents and patient/family satisfaction
mandate, the relationship between the costs, quality and and related indicators will be discussed as it relates to critical care
desired outcomes of care, and the processes involved in nursing.
providing care must be reexamined. The Joint Commission started incorporating NSOIs into its standards
Successful indicators that capture nursing-sensitive patient for accreditation. Nowadays, nursing-sensitive indicators are
outcomes tie together research findings and best practices in an widely used. As an example of how NSOI can be used to monitor
effort to create better patient care. nursing impact, data collection for NSOIs in ICUs started in 2005
in Hong Kong. Currently fifteen ICUs in public hospitals (at Level II
What are nursing sensitive outcome/quality indicators? and above) in Hong Kong contribute to this database. Hong Kong
The American Nurses Association (ANA, 1996) defined nursing- established a set of Specialty Guidelines for ICU nurses in which
sensitive quality indicators as those indicators that capture care or service indicators were listed as follows:
are most affected by nursing care. The use of nurse sensitive quality Patient-focused outcome indicators listed in the Specialty (ICU)
indicators in Intensive Care Units (ICU) has been as a tool to show Guidelines:
the clear linkages between nursing interventions, staffing levels, and
positive patient outcomes. Treatment/care modality indicators:
Nursing sensitive quality indicators (NSQIs) and nursing sensitive • Adverse Incident rates such as medication incident rate, patient
outcomes indicators (NSOIs) are referring to the same thing - fall rate and displacement of tubes; complications such as
patient outcomes that are directly or indirectly influenced by nursing pressure injury rate and nosocomial infection rate; number of
(Dorman, 1977). resuscitation episodes versus successful resuscitation rate.
In 1998, the ANA funded the development of a national database
named as the National Database of Nursing Quality Indicators

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Psychosocial indicators • Numerator statement: total number of patients falls leading to

injury or no injury x1000
• Knowledge level; satisfaction level; number of complaints;
number of compliments. • Denominator statement: total number of patient days during the
period (total number of bed days occupied)
General indicators
Categorization of falls
• Mortality rate; length of stay; unplanned readmission rate.
A patient fall is one of the major clinical risks in the health care setting.
Tracking of the above-mentioned psychosocial indicators and Patient falls have been recognized as a significant adverse event in
general indicators has been conducted at the hospital level. Data hospitals. Falls can be categorized into 3 groups (U.S. Department of
collection has focused on seven NSOIs which are grouped under Veterans Affairs, 2014):
three categories:
• Accidental fall is caused by environmental or extrinsic hazards
Adverse incidents that could result in a trip or slip, which can be prevented by
ensuring environmental safety
• Patient falls • Anticipated physiologic fall is associated with intrinsic factors
• Displacement of tubes, lines and drains such as aging, altered mental state, unsteady gait and sensory
• Medication errors deficits, which can be prevented by specific interventions after
assessment
Complications • Unanticipated physiologic fall is attributed to unexpected
• Pressure injury physiologic events including fainting, orthostatic hypotension,
seizures or the use of sedatives and hypnotics. Although this
• Nosocomial infection (see Chapter 10) type of fall cannot be predicted before the first occurrence,
subsequent fall is preventable (Morse, 2008). Therefore,
Patient and family satisfaction
patient fall is not an inevitable event; it can be prevented when
• Patient and family's satisfaction on the quality of care received. appropriate prevention strategies are implemented.
We revisited the term nursing sensitive outcomes indicators; studied In the hospital setting, patient falls and fall-related injuries are
the topic in depth; confirmed and defined the indicators to be reported; associated with negative consequences on patients, relatives, as
devised NSOI formulas for calculating rates; devised reporting forms well as healthcare providers. Beyond physical injuries, patients
to capture data; designed a Training Need Analysis Tool and refined may experience anxiety, loss of confidence and depression. Fall
questionnaire for satisfaction survey (patient and family). Since early related physical injuries can lead to the escalation of hospital cost.
2005, data on four NSOIs (patient falls, displacement of tubes, lines The costs may be due to extra diagnostic test, treatment for injuries,
and drains, medication errors and pressure injury) were captured in rehabilitation, and extension of the length of hospitalization (Flanders
ICUs (at departmental/unit level) and reported on a six-monthly basis. et al., 2009). Relatives may be anxious, leading to increased
We aimed at capturing quality data for performance improvement complaints and potential litigation. On the other hand, healthcare
and for presenting as a profile of ICU quality in the form of NSOIs providers may also suffer from guilty feeling and shame on the failure
because data collected can be used to compare among ICUs and of care (Patman et al. 2011). Thus, patient falls must be addressed
to trend over time. Hospital-acquired infection (nosocomial infection) as one of the quality-safety indicators for healthcare institutions, and
data were collected by the infection control unit and a satisfaction the ICU.
survey (patient/patient’s family) was conducted at the hospital level.
Hence, an inventory of patient outcomes related to the scope of ICU Data reporting
nursing practice confirmed and data were collected at departmental Web-based electronic systems can be employed to facilitate the
level of all the public hospitals. Examples from this initiative are timely reporting, analysis and recommendation. The following
provided throughout this chapter to highlight the role of the critical information can be included in the fall incident report:
care nurse in improving patient care in the ICU.
• Patient information, such as date of admission, diagnosis, and
premorbid condition, such as conscious level and mobility
ACUTE CARE PATIENT FALL
• Brief description of patient’s action during fall and the reason
NSOI definitions and measurements behind, such as patient’s cognitive and judgment problem,
underlying medical condition, and patient’s condition before fall
Adverse incident: acute care patient fall was underestimated
The World Health Organization (2018) describes “Fall” an event • Immediate consequence such as pain, superficial injury &
which results in a person coming to rest inadvertently on the ground fracture.
or floor or other lower level. Jeffs et al. (2005) defined acute care • Patient’s condition after a fall (nurse’s assessment and
patient fall as the rate per 1000 patient days at which patients observation)
experience an unplanned descent to the floor during the course of
ICU stay. All falls (accidental fall, unanticipated physiologic fall, and • Immediate management such as blood pressure checking,
anticipated physiologic fall) should be reported and described by radiological investigation, dressing and inform relatives.
level of injury or no injury. Falls resulting from violent blows or other A set of comprehensive fall incident data are essential for conducting
purposeful actions should be excluded (US Department of Veterans an effective root-cause-analysis (RCA).
Affairs, 2014).
The measure for the rate per 1,000 bed days occupied at which Potential fall risks in intensive care units
patients experience unplanned descent to the floor during the course The etiology of a fall is multi-factorial. Commonly identified risk
of their hospital stays would be computed as: factors for in-hospital patient falls include:

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Intrinsic factors the isolation room delayed nurses’ responses. Although no fall
incidents inside the isolation room was reported, the risk of fall would
• Age (extremes of age: 1-5 or > 65 years of age)
be anticipated. Critical care nurses should be on the alert for this
• Falls history potential risk and perform frequent patient rounds when patents are
• Syncope syndrome being cared for in the isolation rooms. Overall, critical care nurses
• Continence problems are required to identify the unique risk factors for each individual
patient and implement timely interventions whenever necessary.
• Cognitive impairment
• Postural instability, mobility problems and / or balance problems Fall prevention strategies
• Sensory impairment To prevent falls, an integrated multi-factorial approach is
• Medication such as cardiovascular drugs, drugs used in central recommended as follows:
nervous system, or poly-pharmacy • Identify high risk patient through assessment
• Communication problems • Implement interventions to minimize risk of falls
• Health problems that may increase their risk of fall • Monitor the fall rates

Extrinsic factors • Provide education

• Slippery floor The Morse Fall Scale (MFS) is an individualized criterion-referenced

assessment tool which is designed for measuring the likelihood of
• Inadequate lighting adult patient falls in hospitals. There are a few assessment tools
• Inappropriate height of beds and chairs available which are specific to the ICU setting e.g. St. Thomas’s Risk
• Trailing electric cords Assessment Tool in Falling Elderly in Patients (STRATIFY); Downton
fall risk tool; Tullamore tool; and Tinetti fall risk index.
• Not fitting slippers
Most ICUs in Hong Kong adopt the MFS as their fall risk assessment
(Hong Kong East Cluster, Hospital Authority, Hong Kong: Quality and
tool. It consists of six variables that are quick and easy to be scored,
Safety Office, 2014 & Hong Kong West Cluster, Hospital Authority,
namely: history of falling; secondary diagnosis; the use of ambulatory
Hong Kong: Patient Safety Committee, 2014).
aids; intravenous therapy/intravenous assessment; gait condition;
The etiologies of fall in critically ill patients are specific. The intrinsic and mental status. Each variable is scored from 0 to 30 marks. If the
factors of the falls in ICU include de-conditioning of patients, which score is less than 45 marks, the risk level will be defined as "not at
can occur rapidly after ICU admission. Extrinsic factors are related to risk". If the score is equal to 45 marks or more, the risk level will be
the fall, which are less with slippery floor or lighting but more with the defined as "high". Risk assessment should be done on admission,
amount of tubes, cables, or drainage bags attached to patients. The then to be repeated on regular interval and whenever condition
equipment hinders patient's mobility as well as increases their risk of warrants (i.e. change of health status or after a fall incident). In fact,
falls. The uniqueness of fall risk factors in the ICU generates unique most of the ICU patient scores are high when using the MFS. The
preventive measures (Patman et al., 2011). sensitivity of the tool to differentiate the high risk group patients
may not be absolutely adequate in critical care setting, so clinical
Cases sharing with learning points observation and clinical judgment are indispensable in assessing
fall risks of ICU patients. Developing new fall risk assessment tool
One fall incident happened in Tuen Mun Hospital when patient was
on the uniqueness of critically ill patients should be considered by
sat out in chair with no railing and there existed just a mobile bedside
the critical care nurse to meet their patient care needs as indicated
table nearby. The patient felt tired, and attempted to return to bed by
(Flanders et al., 2009).
himself without notifying nurses. With unsteady gait, he eventually
fell on the floor. After this incident, a “sit out checklist” was developed Interventions (universal or specific) to minimize fall risks
to ensure that safety measures had been taken before we sat the
patient out of bed (see Appendix 1). Two levels of preventive measures could be implemented to target
Furthermore, fall incidents usually happened during meal time fall prevention. Universal fall prevention interventions should be
or during the time when nursing manpower is thin (duty staffs offered to all patients. In addition, specific interventions for high risk
are overloaded with work or being occupied by other patients). groups after professional judgment should be implemented.
Sometimes, inattention or less vigilance of staffs is a risk factor for Universal fall prevention interventions include:
falls in ICUs. Hence, having safety rounds by designated patrol nurses • Orientate patient to ICU environment and routines
at regular intervals and during peak hours is highly recommended.
• Provide call bell in reach and educate the using of call bell
According to the sharing among NSOI sub-committee members, system
certain brands of split type side rails had been identified as a potential
• Respond to patient's call as soon as possible
risk item. They did not cover the full length of the bed; patient could
easily get out of bed by moving to the end of it. It was proven by • Keep the necessary items / frequently used belongings within
one reported incident. NSOI subcommittee members were advised reach of patient
to purchase bed side guard board to fill the gap of the side rail. Nurse • Stabilize the bed, sit out chair and bed rail with brakes locked
executives were recommended to pay more attention to the choice etc.
of bed in the future. • Ensure the patient's clothing and footwear are properly fitted
Moreover, NSOI sub-committee members also identified that a when assist the patient to walk about, e.g. roll up the pants to
negative pressure isolation room had the potential risk for fall. prevent tripping.
Isolation rooms provided a physical barrier and delayed nursing • Advise patient to put on appropriate spectacle or hearing aid to
actions. If a nurse noted a dangerous action of patient inside the improve communication
room, she/he might not be able to approach the patient in time. The
need for putting personal protective equipment on before entering • Provide pamphlet on falls prevention to patient and relative.

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Specific interventions for high risk groups include: The objective scoring system was considered useful to minimize
• Make fall risks as part of nurse-to-nurse report (both at shift the inappropriate use of physical restraint in ICUs, and it provided
change and meal break) autonomy for nurses to make restraint decision. Validation of this
scoring system would be considered in our next step of ward
• Display fall hazard signage on patient's head of bed for better
improvement action.
communication between all healthcare providers
• Relocate agitated patients to easy-observable bed Fall rate monitoring and staff education
• Provide constant inspection / ward round by patrol during peak Ward managers are delegated to report, monitor, analyze the
hour such as meal time and admission of emergency cases trends, and review the preventive measures periodically (Hong Kong
• Provide regular assistance for toileting to patients as required West Cluster: Patient Safety Committee, 2014). Education on falls
• Educate the patient about his/her risks to fall periodically prevention and management are provided for new staff. It should
be included in the preceptorship program and refresher program.
• Inform relatives that the patient is at high falls risk
All staff should be trained with skills to depict reversible risk factors,
• Manage delirium and postural hypotension identify potential fallers and implement appropriate interventions.
• Optimize falls related medication such as psychoactive and In addition, attractive data display boards are recommended to
cardiovascular drugs increase staff's' awaeness. Fall debriefings should be conducted
• Use restraints as last resort and review periodically after each fall incident to establish non-punitive culture for learning
and improvement (New Territories West Cluster: Clinical Service/
• Address identified falls risk to general ward staff when discharge Chairperson of Cluster Clinical Governance Committee, 2018). Staff
from ICU engagement in fall investigation and sharing the recommendations
(Kowloon Central Cluster, Hospital Authority, Hong Kong: Task with staff are successful elements on fall prevention management.
Group on Patient Falls, 2014; Hong Kong East Cluster: Quality &
Safety Office, 2014; New Territories West Cluster: Clinical Service/ Improvement initiative
Chairperson of Cluster Clinical Governance Committee, 2018; Hong
As a quality improvement initiative, Physical Restraint Taskforce was
Kong West Cluster: Patient Safety Committee, 2014).
established under Specialty Advisory Group (Critical Care) in 2013
to evaluate nursing practice on physical restraint utilization in local
Physical restraints ICUs. Physical restraint related data were prospectively collected
between January 2015 and December 2015. Total 1805 patients
Physical restraints should be used as a last resort since it can be both
were recruited in the survey period. 731 patients were physically
humiliating and harmful (HAHO, 2016). Critical care nurses should
restrained (prevalence rate≈ 40.5%). Patients in restrained group
follow hospital guidelines on applying physical restraints on patients
were generally older (p < 0.01), predominantly male (p < .01) and
and providing appropriate observation and care to the restrained.
had a lower GCS score (p < 0.01). More restrained patients were
The value of applying physical restraints in ICU should be receiving invasive mechanical ventilation (p < 0.01), being nursed
evaluated regularly. As an example, in 2012, Tuen Mun Hospital in isolation room (p = 0.01) or had a past history of fall (p < 0.01) or
ICU implemented a quality improvement program on Application of self-extubation (p < 0.01). No major restraint-associated injury was
Physical Restraints. The aims of this program were to minimize the reported.
inappropriate use of physical restraint, and ensure patients’ dignity
According to the survey results, a nursing practice guide on use of
and safety.
physical restraint in intensive care units was finalized in 2017. The
A scoring tool was established to provide an objective guide for guide included recommendations on risk assessment, care process,
nurses when applying physical restraint. The scoring tool included and system and support. The intent of this guide is to encourage safe
patient’s behavior and muscle power, the types of medical devices/ and appropriate use of physical restraints in intensive care units.
equipment that the patient had as well as special considerations. (Specialty Advisory Group: Physical Restraint Taskforce, 2017).
Patients are categorized under three color zone according to the
total score: Red, Yellow and Green. DISPLACEMENT OF TUBES (ENDOTRACHEAL/TRACHEOSTOMY) i.e.
• Red zone - restraint should be considered as necessary for the UNINTENDED EXTUBATION, LINES AND DRAINS
best interest of patients
• Yellow zone - decision of using physical restraint is subjected to An unintended incident during which the appropriate marking on the
nurses’ judgment tube inserted is found to be different from the previous observation
or previous record, and the primary function of the tube cannot be
• Green zone - restraint should not be applied (see Appendix 2). achieved.
Electronic calculation of restraint score has been installed in The measure for the rate per 1,000 bed days occupied would be
the Clinical Information System of the hospital to facilitate the computed as:
implementation. Signage is hung on each bed as a reminder. A • Numerator statement: total number of confirmed unintentional
clinical audit on the use of the scoring tool was conducted from displacement of tubes/lines/drains x1000
September 2012 to December 2012. Compliance rates of using the
scoring tool and inappropriateness of using restraint were evaluated. • Denominator statement: total number of patient days (bed days
occupied) within the period.
A total of 555 ICU patient episodes were involved in the evaluation.
The compliance rate of using the scoring tool was 80%. Approximately, Country specific exemplar focusing on decreasing displacement of tubes
40% of patients were physically restrained at the time of audit; the (endotracheal/tracheostomy, i.e. unintended extubation), lines and
prevalence rate was similar to the background rate which was 35% drains
according to the prevalence study. Inappropriateness was much
improved, decreasing from 12% to 5% of patient episodes after the The majority of the ICUs in Hong Kong are within the public sector.
project was implemented. A total of 40% of patient episodes were There exists an electronic self-reporting system for reporting incidents
not restrained as they were categorized under the Yellow zone. in all public hospitals in Hong Kong. In view of the uniqueness of

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each ICU, the incident rate may not truly reflect the performance of
individual hospitals. However, the result thus generated from 15 Adult
ICUs still can serve as a reference when we compare the trend of
performance of individual hospital and the aggregated numbers of all
hospitals. Basing on the analysis, contributing factors and orrelating
factors are mapped out and comments and recommendations are
summarized for quality improvement purposes.

Content of the reporting form

The self-reporting form (see Appendix 3) includes the patient's
personal particulars; date and time of incident; personnel involved
regarding the displacement; description of incident; details about
the displaced tube/line/drain; factors contributing to incident; patient
outcome; and evaluation.
Table 1. Patient days across all the 15 adult ICUs
Background information of the incident includes incident occurred
during shift handover or meal break, and/or when patient undergoing
nursing procedures like bed bathing, position turning, ambulatory
activities, admission and discharge activities, or transportation,
medical procedures or other procedures, or when case nurse being
occupied by care of another patient, preparation of works or ward
round. Patient factors include whether the patient received sedation,
was restless, any communication problems, being physically
restrained (secured or loosen), and level of cooperation.
The report also includes system and human factors that contribute
to the incident. For the system factors, the nurse could select one
or more items including poor design or maintenance of device, poor
quality of material, poorly secured tube/drain/line, high activity level,
below normal staff and patient ratio, inadequate staff training, and
inconvenient patient location including those in the side or isolation
Table 2. Number of dsiplacements across all the 15 adult ICUs
room. For the human factors, the nurse could choose inadequate
patient assessment, incompetent in or unfamiliar with unit protocol or
guidelines, distraction, or inattention.
The patient outcome also needs to be reported if the displaced tube/
line/drain will require reinsertion and/or re-intubation within 24 hours.
The case nurse also evaluates whether the incident is avoidable
or unavoidable and recommends any improvement initiatives to
avoid the incident happening again. The self-report is reviewed by
a shift in-charge or senior nurse to check whether the input data are
accurate or not.

Summary of data
Data were collected from 15 hospitals and analyzed for the period
from January 2014 through December 2016.

The overall patient bed day occupancy (BDO) increased from Table 3. Displacements per 1000 bed days across all the 15 adult ICUs
31,631 (2014) to 32,578 (2016) (see Table 1). The total number of
displacement slightly increased from 195 to 208 incidents (see Table
2). The total displacement incidents also increased from 6.4 in July
to December 2014 (see Table 3) to 7.8. Compared 31,547 BDO
in July - December 2014 with 33,040 BDO in January-June 2015.
The incidence rate was similar between July-December 2015 and
January-June 2016.

However, the total number of displacement had slightly increased

especially on drains and the rest remained the same throughout the
reviewed period (see Table 4). Displacement of endotracheal tube
(ETT) and tracheostomy tube (TT) may have serious life threatening
outcomes. It is observed that patients usually received less, or even
no, sedation during weaning which further increases their discomfort
when they have to cope with their physiological stress of the weaning
process.
The nursing strategies may be promoting patient comfort during
intubation, better communication between nurse and patient, and Table 4. Breakdown of displacement incident rate by tube type
nurses staying at the bed-side to decrease the risk of self-extubation.

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Displacement of central venous catheter (CVC) and renal Assigning staff as patrol nurses to perform patient safety rounds
replacement vascular accesses (haemodialysis catheter) might would be recommended especially during high risk period.
cause interruption of life saving therapies. Most of the causes
were related to inadequate anchoring of the catheter, e.g. the CVC Factors contributing to the incidents
inserted in operation theatre had frequently no anchoring stitches
Patient factors
applied. Therefore, the catheter would easily displace or dislodge.
Avoidance of vascular line displacement remains an important focus The presence of tube, line and drain might cause great discomfort to
to address, in particular about the practice of securing the catheters. patients. Nursing measures were implemented to minimize patient’s
discomfort including nurse reassurance, effective communication,
Displacement of nasogastric tube (NGT) for feeding accounted
and appropriate use of physical restraint. There were many cases
for high percentages in several reports. The NGT is the most
when physical restraints were applied and periodic reviews on the
commonly used tube being inserted in ICUs. Usually no anchoring
effectiveness of restraint were needed. As mentioned earlier in
stitch is applied and patients may easily pull it out. Although no
this report, patients with minimal or no sedation during weaning
life threatening incident that was due to nasogastric feeding tube
stage were running the risk of having tube/line/drain displacement
displacement was recorded, the displacement could contribute to
incident(s). Effective communication between doctors, nurses and
higher risk of aspiration, and the repeated insertions could cause
the healthcare team members is essential to ensure a balance
discomfort and injury to patient. It is highly recommended to make an
between appropriate sedation and prevention of displacement
extra effort in securing the NGT, especially when it serves as a drain
incidents.
and is placed intra-operatively. On the other hand, the displacement
of thoracic drains may cause potential fatal outcomes such as System factors
tension pneumothorax. Therefore, it is highly recommended that The commonest cause of displacement incidents was due to high
individual hospitals should pay attention to the rising trend and focus activity levels. This implied that nurses were occupied by various
on prevention of these incidents. activities and attention to certain patients could have been diverted.
In our experience most of the tube displacements happened during Poorly secured tube/line/drain was the second commonest system
night shifts. However, when the length of shift was taken into factor contributing to displacement incidents. Individual ICUs should
account, the incident rate during night shift was nearly the same as continue to work out the best methods to avoid incidents. Patient’s in
day time. While the nurse: patient ratio for night shifts was less in isolation rooms was the third common system factor. Nevertheless
most hospitals in the public system, it was recommended that nurses with the increase in awareness of infection control measures, there
should make extra efforts to maintain the quality of care during night might be more patients requiring isolation. It was recommended that
shifts. nurses should be more alert to patients located in isolation rooms.

Analysis of incidents Patient outcomes

The top three environmental factors contributing to occurrence Artificial airway is a very important life saving device for ICU patients.
of incidents (see Table 5) were when nurses were occupied with Among those displacement of ETT and TT, an average of 32% of the
providing care to other patients, during meal / tea break and during related patients required re-intubation. Individual ICUs should pay
nursing procedures. This implied that patients being less attended to special attention to their own incidents and implement appropriate
or unattended had a higher risk of displacement of tube/line/drain. preventive measures to prevent tube displacement. Findings from
These reasons appear to be related to the nurse: patient ratio during January 2014 to December 2016 (see Table 6) showed no significant
night shifts. differences in the requirement of reinsertion of line or drain after
displacement.

Table 5. Tube displacement correlation with other activities occupying

nurse’s attention

The presence of the ICU nurse was a crucial factor in prevention

of tube displacement incidents. It would be necessary to adjust the
manpower arrangement during meal time or tea breaks because it was Table 6. Reintubation (ETT) and reinsertion (TT) rates in source ICUs
found that during shift hand-over and meal/tea break, patients were
prone to have tube/line/drain displacement. In addition, arrangement Conclusion
of work to perform non-urgent labour intensive activities should be The overall ICU displacement incidents were similar in contrast with
done only when there was adequate manpower. Around average the increasing bed days occupied, which reflected that the current
42% half yearly of tube/line/drain displacement incidents occurred measures in preventing displacement incidents among various
during nurses occupied by other patients. It is recommended that hospitals were effective. It requires a multi-disciplinary approach in
nurses should be more alert to maintain all tubes, lines and drains preventing displacement incidents. Effective communication among
during procedures to prevent displacement. doctors, nurses and health care assistants is essential. Identifying

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patients at risk, time at risk can help to initiate proactive measures to Medication errors are major issues in the health care setting and
prevent line/tube displacement. particularly prevalent in highly technical specialty areas such as the
ICU. Medication incident (MI) which stresses the quality processes
Recommendations of the drug administration, is now used in modern literature.
It was found that the types of tube displacement with high incidence Medication incidents include errors in prescribing, dispensing and
rates over the period of two years (2015 to 2016) were endotracheal drug administrations. The incidents may be patient involved or non-
tubes and nasogastric tubes. Frequent reminders and explanation to patient-involved.
patients about the importance of the tubes could help to prevent self-
Instruments measuring medication incidents in ICU
extubation. Debriefing of the incidents to all frontline staff to aware
their alertness in the prevention of displacement of life supporting The measure for the medication incident rate per 1,000 bed days
devices especially for patient in side ward or isolation room. Staff occupied would be computed as:
should be on the alert for restless and uncooperative patients during • Numerator statement: total number of medication incident
duty handover. Before leaving the at-risk patients, nurses should occurred x1000
ensure that all life supporting devices are properly secured and, if
• Denominator statement: total number of patient days during the
necessary make arrangement for supporting staff to actively monitor
patients. period (total number of bed days occupied).
Appropriate staff deployment could minimize the occurrence of Medication incidents in ICU
incidents. Nurses should be encouraged to call for help when they
are expected to be occupied for a long period of time. Reassurance Critically ill patients receive nearly twice as many medications
and promotion of comfort could help to gain the cooperation from as patients in general care units, and as a result, are at risk for a
patients. potentially life-threatening error during their hospital stay (Eric
2008). According to Kane-gill, Jacobi and Rothschild (2010),
Senior nurses should remind staff to hold tubes, lines and drains
medication errors happened more frequent in ICU with a greater
carefully and stay alert when they are repositioning patients and/or
likelihood of harm in ICU patients, whereas the chance of mortality
equipment.
is approximately a 2.5 times higher in ICU. In adult ICU, the median
Reviewing major incidents, especially the avoidable cases, could frequency of medication errors is 106 per 1000 patient days.
raise staff awareness. Posting of the incident numbers and trends
Patients in the ICU are at higher risk for adverse drug events for many
in the working area can remind and enhance staff alertness.
reasons. These include illness severity, complexity of care, frequent
Heightened staff awareness coupled with caring attitude is essential
use of complex drug regimens, high-alert medications, and the need
to minimizing displacement incidents.
for frequent drug dosing. Additionally, the busy environment, heavy
The way forward workload and frequent stressful situation for the staff can predispose
the ICU setting to having a greater incidence of medication errors
It is proposed to enhance communication between doctors and nurses (Vos, et al., 2007).
during weaning stages for sedation control, and the appropriate time
for extubation. With an aim to shorten patient's length of stay in ICU, Data reporting
trials on nurse initiated extubation in weaning patients from ventilators
Medication error (ME) in ICU can place patients at risk of injury
may be able to minimize displacement incidents. Furthermore,
or death. It is essential to minimize and prevent the incidence of
proper use of sedation scoring scales could minimize patients'
medication errors, hence offering the best protection to our patients.
discomfort. Periodic patient safety rounds are a pro-active measure
A comprehensive data collection system with the aim to establish a
to identify patients at risk of incidental displacement so that prompt
database on medication errors which includes all error reports related
preventive measures can be implemented. Briefing and debriefing
to medication use in the prescribing, administration, dispensing and
on post displacement incidents are encouraged so as to have the
preparation is needed.
cases reviewed and good practices shared in order to achieve better
patient outcomes. Near-displaced incidents should be mentioned to The Advanced Incident Reporting System (AIRS) was used in public
colleagues to prevent displacement to happen on the same patients hospitals in Hong Kong for reporting all incidents including medication
again. It is invaluable to continue having this self-reporting system of incidents. AIRS is a web-based electronic system serving as a tool to
displacement incidents with a blame-free or no blame culture. support risk management by facilitating the reporting, classification,
analysis, management of incidents and marking improvement. The
report includes the following information: patient information, the
MEDICATION ERRORS IN THE ICU
location and time of the incident, a description of what happened
Medication error (ME) and medication incident (MI) and what was done about it, the condition of the patient, the event
outcome, severity index describing patient outcomes following
The National Coordinating Council for Medication Error Reporting medication errors, as in Table 7, and any additional information
and Prevention (2009) defined a medication error as: required by the facility policy.
any preventable event that may cause or lead to inappropriate A comprehensive medication incident form is essential for the data
medication use or patient harm while the medication is in collection and for root cause analysis to evaluate the factors and
the control of health care professional, patient, or consumer. prevention measures for improvement in medical safety, such as
Such events may be related to professional practice, health Appendix 4.
care products, procedures, and systems.
Another extensive review of medication safety in the ICU by Kane-Gill
et al. (2006) defined medication errors as:
preventable mistakes or a deviation in planned action.

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In a large-scale cross-sectional study in the United States, the

types and causes of the medication errors between ICU and non-
ICU setting were compared (Latif, et al., 2003). It was revealed
that medication errors often originated in the administration phase
(ICU 44% versus non-ICU 33%). The most common error type was
omission (ICU 26% vs. non-ICU 28%).
Among harmful errors, dispensing devices (ICU 14% versus non-
ICU 7.1%) and calculation mistakes (ICU 9.8% vs. non-ICU 5.3%)
were more commonly identified.

Local data on medication incidents

In Hong Kong, similar trends in medication incidents was observed.
In 2016, it was reported that the medication errors were also often
4.
originated in the administration phase (see Table 8) (Hospital
Table 7. Classification of patient injury (Hospital Authority, 2018) Authority, 2018).
Types and causes of medication errors According to the annual report on sentinel and serious untoward
events published by Hospital Authority (2018), the top three common
Possible medication errors may arise during any of these steps. category of drugs involved in the medication errors were “known
The types of medications errors can be grouped under three key drug allergen”, “dangerous drug” and “anticoagulant” (see Figure
processes: 1). Medications such as insulin, inotropes and oral hypoglycaemic
Prescribing agents were also commonly involved in medication incidents.
• wrong drug Among the medication incidents related to known drug allergen, the
three most commonly involved drug allergen were penicillin-related
• wrong dosage form
medications, non-steroidal anti-inflammatory drugs and paracetamol.
• wrong strength/dosage
• wrong duration
• wrong frequency
• wrong route
• wrong abbreviation
• wrong instruction
• wrong patient
• double entry
• drug omission
• known drug allergy
Dispensing
• wrong drug
• wrong dosage form
• wrong strength/dosage
• wrong quantity
• known drug allergy
• wrong patient
Table 8. Number of medication incidents (by type) reported in AIRS in
• wrong label information
Hong Kong (Hospital Authority, 2018)
• double dispensing
• drug omission
Administration processes
• wrong drug
• wrong dosage form
• wrong dose
• wrong flow rate
• wrong patient
• wrong route/method
• wrong iv diluent
• wrong time
• extra dose Figure 1. Yearly trend of top three common drugs involved in medication
• dose omission incidents. (Hospital Authority, 2018)
• unordered drug
• known drug allergy
}

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 Nursing Sensitive Outcome Indicators

Impacts and consequences on healthcare professionals and patients in various ways, for instance, illegibility of orders, incomplete orders,
incorrect doses, inappropriate doses for narrow therapeutic range
Medication errors are more common in ICU due to poly-pharmacy
for liver or kidney function, failure to verify allergies, and failure to
and the stressful environment. Despite the best efforts in the midst of
reconcile medications leading to omitted medications or extra doses
our daily work, medication errors can occur.
of medications (Bohomol, 2009; Frith, 2013).
Apart from causing considerable mortality, morbidity, and additional
In a study of prescribing errors. 7.53 errors per 1000 prescriptions
health care costs, it also poses substantial impact and consequences
were identified (Jayawardena, 2007). Research explored the effect
on health care practitioners and patients when a medication error
of perceived stress; caseload, perceived workload, and hours of
occurs (Benkirane, 2009).
sleep of physician on medication errors (Eric et al., 2008). Clinicians
Health care professionals should understand the reasons for medication errors from a human
factor perspective.
However, little attention has been paid to the feelings of health
care professionals involved in the incidents. They may experience Pharmacists and dispensers
uncomfortable feelings of personal vulnerability and professional
Hospital pharmacies dispense large numbers of medication doses for
fallibility; guilt, panic, remorse, self-doubt, and self-blame (Porter
hospitalized patients. Previous studies have also reported conflicting
2014). Some may be fearful about the safety of their patients and
rates of pharmacy dispensing errors, ranging from 0.0041% to 3.6%.
about disciplinary actions and punishment for their mistakes; fear
One study relied on self-reporting to detect dispensing errors and
malpractice lawsuits and possible criminal charges if a fatal incident
identified underestimation of the incidence of these errors (Brixey
occurs (Eric et al., 2008). They may even have feelings of doubt
2008). The study found an overall unweighted pharmacy dispensing
about their professional abilities. Healthcare personnel involved in an
error rate of 3.6% (5,075), of which 2.9% (4, 016) were detected
incident can benefit from psychological support which can create an
errors and 0.75% (1,059) was undetected errors. Several factors
environment that fosters open and honest discussion about errors.
identified in the dispensing process included human fatigue, process
Nurses workarounds, confusion surrounding look-alike and sound-alike
medications, and repetitive tasks for filing and checking the dose
Fears of negative consequences can be a major obstacle to accurate dispensed. The process involved routinely used medication; the
reporting of errors, with as many as 50% to 96% underreported. high volume of medications filled and verified can also lead to a high
How nurses choose to respond to the occurrence of a medication number of errors.
error is recognized as an ethical imperative (Gallagher, 2008). It
is not an easy action to divulge medication errors. Nurses are still Patients and family
expected to provide responsible care and be fully accountable within
A systematic review of direct observation evidence over medication
their scope of practice. When medication errors are discovered,
errors in critically ill adults showed that increased monitoring was
nurses have moral obligations of accountability and responsibility to
the most common consequence of medication errors, whilst life-
account for the mistakes with disclosure (Porter, 2014). It is also an
threatening and fatal adverse events were rare (Kiekkas, 2011).
opportunity to practice virtuous characteristics, particularly honesty
and trustworthiness. Patients in the ICU and their families are most vulnerable. They have
limited ability to control the environment and invasive technology and
Research has demonstrated that four factors affect nurses’
a sense of intimidation by the critical illness experience. A climate
willingness to respond to an ethical dilemma or question, such as
of trust is indispensible for patients and families to overcome their
whether to report a medication error: ethics knowledge, clinical
vulnerability and powerlessness (Porter, 2014).
expertise, concern for ethical issues, and nurses’ perceived level of
influence in their unit (Hamric, 1999). There are several strategies Risk factors and prevention measures
for ethical responses surrounding medication errors in ICU (Porter
2014): A thorough root causes analysis is commonly conducted in the
organization for error analysis and revealing underlying system
• Be accountable to yourself and your coworkers
deficiencies and contributing factors. Medication errors (MEs) are
• Admit when medication errors occur more common in the ICU due to poly-pharmacy and the stressful
• Resist the culture of Name, Blame, and Shame environment. The underlying cause for such errors could be multi-
• Avoid workarounds in medication management processes. faceted, including mishaps in professional practice, health care
products, procedures and system-related causes (Agalu et al., 2012).
Whenever a patient has experienced an iatrogenic injury, disclosure
Human factors such as fatigue, stress and knowledge deficit of the
of the incident should take place and should be guided by the
healthcare professionals were also contributed to the occurrence
following principles (Camiré 2009):
of medication errors (Benkirane et al., 2009; Frith, 2013; Moyen et
• Perform in a timely fashion – as soon as possible after the injury, al., 2008). High workload, complex and noisy environment in ICU,
while ensuring the patient’s well-being system failures such as lack of protocol standardization and poor fit
• Perform in a quiet room free of interruptions of health information technology to the system workflow were also
• Disclose facts without speculation, opinion or blame the leading causes of medication errors in ICU (Benkirane et al.,
2009; Bohomol et al.,2009; Frith, 2013; Moyen et al., 2008).
• Use simple, unambiguous lay words
The potential risk factors for medication errors in ICU are categorized
• Include an expression of sympathy in Table 9 (Moyen 2008).
• Allow time for questions Ensuring patient safety and providing high quality care are the top
• Document disclosure in the medical record. priority for all healthcare professionals. In order to develop an ideal
patient safety culture in ICU, multiple medication errors prevention
Physicians strategies should be incorporated in all phases of medication use
Physicians have the responsibility to write orders for medications process (prescribing, dispensing, administration and monitoring). An
and prescribe medications. At this vital first step, errors can occur evidence-based clinical guideline on safe medication use in ICU was

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published by American College of Critical Care Medicine (Kane-Gill, Quality Grading Rating
et al., 2017) and some recommendations to improve safe medication
use in critical care setting were extracted and listed as below (Tables Grade A (High) Grade 1 (Strong)
10 and 11). Grade B (Moderate) Grade 2 (Weak)
Nurses often act as ‘the last gatekeeper’ in the process of Grade C (Low) Grade 0 (No evidence)
medication administration. However, interruptions during medication Grade D (Very Low)
administration process can range from questions from other
Table 10. Grade of Recommendation Assessment, Development, and
colleagues, patients, families; monitors, alarms, and pagers to
Evaluation (GRADE) system (Kane-Gill et al., 2017)
patient activity (Academic Medical Center, 2012).
ICU nurses also play crucial roles in setting strategic goals for Grade Recommendations Outcome
medication safety and help in executing those goals and maintaining
safety culture in hospital. Some more essential practice strategies 1 2D Changes in the culture Less time-consuming in
(Frith, 2013) and preventive measures which could improve of safety (non-punitive reporting system
medication safety in ICU were listed in the table below (see Table environment and improve Increased reporting rate
reporting system) of medication errors
6, 7 and 8).
2 2C Initiate education intervention Change in behavior and
Patient and family satisfaction in the ICU (simulation training, associated outcome
Promoting patient and family satisfaction with care is a key multidiscipnary involvement,
component of providing quality care in the ICU (de-la-Cueva-Ariza active engagement of staff,
work standardization)
et al., 2013). Traditionally, the goal of intensive care nursing has
primarily focused on the physiological and psychological impact of 3 2B Implement hospital-wide Help in the
life-threatening illnesses on individual patients. By incorporating the Computer Providing Order completeness of the
concept of patient to include the family, the critically ill patient’s well- Entry (CPOE) system prescription
being can be improved (Lee, Chien, & Machenzie, 2000). For that Ddecreased omission
reason, both patient and family experience is important for patient- errors compared with
and family-centered care in the ICU. hand-written orders
(Maat et al., 2014)
Patient and family satisfaction has become an acknowledged
quality metric in the ICU. A number of studies have been conducted 4 2C Use of clinical decisin support Decrease the number of
internationally which focus on improving the patient experience system (CDSS) including medication errors
in the ICU. A pilot study was conducted in a mixed adult ICU in drug allergy checking, basic Provide instant, accurate
Netherland using a self-developed questionnaire which included dosing guidance, formulary and reliable electronic
60 questions in eight domains (General satisfaction, Reception, decision support, duplicate order communication &
Physical care, Mental care, Empathy and attention, Communication therapy checking, and drug– was more legible than
drug interaction checking hand-written orders
and information, Surroundings and Physical discomfort) to measure
(Kuperman et al., 2007).
the level of patient satisfaction and to identify its influencing factors
on ICU patients. Ninety-eight patients were interviewed. The mean 5 2B Use of evidence-based Promote safe practice
overall patient satisfaction score was 4.60 out of 5. Communication protocols/bundles such as and decrease variability
and information emerged to be significant in predicting general insulin protocol of medications
satisfaction. Moreover, elderly, female, Dutch nationality, longer ICU prescription among
stay, long duration of mechanical ventilation and a high Minimal prescribers and reduce
MEs
Mental State Examination score were related to less satisfied
patients (Jansen et al., 2008). 6 2B Use of medication labeling Help to visually
practice using tall man differentiate look-alike
(uppercase) letters such drug names
as DOBUTamine and
DOPamine instead of
dobutamine and dopamine
7 1B Comply with safe medication Reduce incorrect
concentration practice using calculations.
of premade IV preparation erroneously prepared
such as parenteral products concentrations, wrong
diluents, improper
labeling and expiration
dates when in manual
preparation (Kane-Gill et
al., 2017)
8 2C Use of smart IV infusion Reduce rate of MEs
pump with use dose error Assist the frontline
reduction software (drug nurses to select
libraries) and displayed drug appropriate programmed
name medication, and
calculate both the dose
and delivery rates
(Trbovich et al., 2010)
Table 9. Potential risk factors for medication errors in ICU (Moyen, et al., Table 11. Recommendation guidelines of preventive measures (Kane-Gill
2008) et al., 2017)
}

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Table 12. Essential practice strategies to improve medication safety in ICU

(Frith, 2013)

Figure 3. Strategies for improving medication safety (AMC, 2012)

Patient satisfaction has been associated with nursing work

environment. Boev (2011) used a 26-item instrument to measure
level of satisfaction of critically ill patients with care and to examine
the relationship between nurses’ perception of work environment
and patient satisfaction in four adult ICUs in United State. The
results showed that overall quality of nursing had the highest
score (4.5 out of 5), followed by nurses’ friendliness (4.4 out of 5),
and patient’s satisfaction of pain control (4.4 out of 5). Critically
ill patient’s satisfaction with preparation for ICU discharge had
the lowest scores (4.1 out of 5). Intensive care nurses reported
moderate satisfaction with work environment, with perception of the
role of their nurse manager having a strong influence on satisfaction
scores. Perception of nurse manager leadership and capability was
significantly associated with patient satisfaction. The relationship
between nurses’ perception of their nurse manger and overall
patient satisfaction suggests hospitals should consider putting more
resources in nursing work environment improvement and nursing
leadership empowerment.
However, conducting patient satisfaction surveys in the ICU can be
challenging. Apart from whether critically ill patients can consciously
recall their stay in the ICU, and have the ability to judge quality of
health care service, the timing to perform the survey is another major
issue. Most patient satisfaction surveys are conducted upon patient
discharge and reflect the care they received from the unit from
which they were discharged. Rarely are patients directly discharged
to home from the ICU, and obtaining information related to patient
satisfaction with ICU nursing care is therefore limited (Stricker et.al.,
2011).
Additionally, there are a lack of validated instruments to evaluate
patient satisfaction with care in the ICU and the absence of
standardized instruments make benchmarking of patient satisfaction
data difficult (De-la-Cueva-Ariza et al., 2013).

Instruments measuring family satisfaction

Figure 2. Preventive measures for medication errors Studies demonstrate that if a critically ill patient is unable to rate
satisfaction with care in the ICU, family members can be taken as

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 Nursing Sensitive Outcome Indicators

appropriate surrogates (Stricker et.al. 2011). Therefore, various satisfaction with overall care in ICU. The content and construct
assessment tools had been developed to evaluate family’s satisfaction validity were examined by Wasser and colleagues (2001), support
in ICU (Heyland & Tranner, 2001; Wasser et al., 2001). A search of that the CCFSS was reliable and valid; the Cronbach’s alpha score
literature had shown that there are at least three assessment tools was 0.93 for the 4-factor model, and 0.91 for 5-factor model. The
commonly used in ICU to measure the level of family satisfaction. CCFSS has five subscales: assurance (the need to feel hope for a
desired outcome), information (the need for consistent, realistic and
Family satisfaction in intensive care unit (FS-ICU)
timely information), proximity (the need for personal contact and to
The FS-ICU-34 was developed by Heyland and Tranmer (2001). be physically and emotionally near patient), support (the need for
It was designed to measure the family satisfaction with care resources, support system, and ventilation), comfort (the need for
provided in the ICU. The origin FS-ICU consists of 34 items, it was personal comfort). Subscale correlation were not lower than 0.75 for
conceptualized into two domains: satisfaction with overall care (18 the five-factor model and 0.856 for the four-factor model (Wasser et
items), and satisfaction with decision making (16 items). Content al., 2001).
validity, clarity and readability had been tested. Cronbach’s alpha
(internal consistency) ranged from 0.74 to 0.95, and test and retest Clinical exemplar: family satisfaction in Hong Kong ICU
reliability was 0.85 (Heyland & Tranmer, 2001). Reporting family members’ feedback and satisfaction of care is a
The FS-ICU-34 was further refined and validated by Wall and his key domain to provide transparency and improve the overall quality
colleagues (2007), and became shortened FS-ICU-24. Shortened of intensive care. Three quantitative studies were identified using
FS-ICU-24 consists of 24 items, measuring two domains as well: the CCFNI and FS-ICU to investigate the needs and satisfaction of
“Satisfaction with Care” (14 items) and Satisfaction with Decision family members of critically ill patients in Hong Kong.
Making (10 items). The Cronbach’s alpha score were 0.92 and 0.88 Lee et al. (2000) conducted a descriptive study consisting of 30
for the Satisfaction with Care and the Satisfaction with Decision family members who had a relative admitted to a Hong Kong ICU to
Making respectively. The two subscales showed good correlation explore their needs and their perception of having their needs met.
with each other (Spearman’s 0.73, p < 0.001) which “suggesting that Among the five need categories, reassurance and information were
a single scale for the entire instrument was reasonable” (Wall, et the most important categories. The five most important family needs
al., 2007, p.275). In validity testing, the FS-ICU-24 was significantly were ‘to know the expected outcome’, ‘to be assured that the best
correlated with the Family-Quality of Dying and Death (Family- care possible is being given to the patient’, ‘to know specific facts
QODD) questionnaire total score (Spearman’s 0.56, p < 0.001) (Wall, concerning the patient’s progress’, ‘to have explanations given that
et al., 2007). are understandable’ and ‘to see the patient frequently”. Over 80% of
The FS-ICU has been translated and validated for cross-cultural use. family members perceived nurses as the most appropriate persons
To date, it had been translated into French, Chinese, Portuguese, to meet the family needs. Additionally, the five family needs that could
Hebrew, Spanish and Swedish (Canadian Association of Research be best met by nurses were ‘to talk to same nurse everyday’, ‘to be
at the End of Life Network, n.d.) as it is a valid and reliable tool called at home about changes in the patient’s condition’, ‘to receive
for assessing family satisfaction in the ICU. The Pamela Youle information about the patient at least once a day’, ‘to have directions
Nethersole Eastern hospital in Hong Kong currently adopts FS- as to what to do at the bedside’ and ‘to help with the patient’s physical
ICU-24 as an instrument to measure the family satisfaction of care care’. The study identified that female family members had higher
in ICU. ratings in the unmet need scores and the 5 highest ranking of the
unmet needs included ‘to talk to the doctor daily’, ‘to visit any time’,
Critical Care Family Need Inventory (CCFNI) ‘to help with the patient’s physical care’, ‘to feel it is alright to cry’ and
The CCFNI is a 46-item, 4-point Likert-type questionnaire with 45 ‘to talk about negative feelings such as guilt or anger’.
specific items and an open-ended item to identify a need that was not Another similar descriptive study was carried out in Hong Kong to
listed on the questionnaire. The CCFNI was developed and modified investigate the needs of family members of ICU patients and to
from Molter’s (1979) instrument by Leske in 1986 (Lee & Lau, 2002). measure the extent of needs being met. The study recruited 40 adult
Construct validity and internal consistency of CCFNI were examined family members of critically ill patients using convenience sampling
by Leske (1991), and were established by performing factor analysis. methods. The mean scores of five need categories ranged from 2.5
Five dimensions of CCFNI were identified, and were labeled as to 3.7(possible range 1-4). The reassurance category was ranked
need for support, comfort, information, closeness and reassurance as the most important then followed by closeness, information,
(Leske, 1991). The internal consistency alpha coefficient of the total comfort and support category. More than half (58.4%) of the family
CCFNI was 0.92, and the Cronbach’s alphas of five dimensions were members of critically ill patients replied that their needs were met.
between 0.61 and 0.88. This indicated that CCFNI had acceptable The top 5 needs that were met most were ‘to know the expected
internal consistency. outcome’ (95.0%), ‘to have friends nearby for support’ (95.0%), ‘to
The CCFNI has been widely used in studies and in different cultures be assured that the best care possible is being giving to the patient’
in large scale studies (Azoulay et al., 2001; Damghi et al., 2008; (95.0%), ‘to feel that hospital personnel care about the patient’
Wilson et al., 1998). It has been translated into Arabic (Damghi et (94.9%) and ‘to have visiting hours start on time’ (92.5%) and they
al., 2008), Spanish (Gomez-Martiinez et al., 2011), Chinese (Wong, were met by nurses and doctors. Needs of the reassurance category
1995). According to the systematic review by van den Broek (2018), were met most (86.7%), then the closeness (61.6%), information
CCFN and FS-ICU were the most reliable and valid questionnaires (56.8%), support (54.7%) and comfort (35.4%) categories. Nine
in relation to their psychometric properties. out of 10 needs that were met most were perceived as important
which implies the health care providers satisfactorily fulfilled family
Critical Care Family Satisfaction Survey (CCFSS) members’ needs. On the other hand, the top 5 needs were met least
were ‘to have comfortable furniture in the waiting room’( 12.5%), ‘
The CCFSS was developed and validated by Wasser et al. (2001). to have a toilet near the waiting room’ (12.5%), ‘ to have good food
They believed that it is important to include all dimensions of care available in the hospital (18.7%), ‘to have the waiting room near the
when evaluating family satisfaction with care provided in ICU. patient’(22.5%) and ‘to visit at any time’(25%). (Lee & Lau, 2003).
The CCFSS consists of 20 items; it is used to measure family Apart from the two studies using CCFNI, the Hong Kong Association

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 Nursing Sensitive Outcome Indicators

of Critical Care Nurses (HKACCN) conducted a pilot study in 2004 Strategies to improve family satisfaction on information needs
to examine both patient and family satisfaction with nursing care in
Use of printed information is an effective method in meeting family
3 Hong Kong ICUs. 30 samples from patients and 30 samples from
information needs. Azoulay et al. (2002) conducted a randomized
family members of ICU patients were recruited. Patients who are
trial in 34 French ICUs to compare comprehension of diagnosis,
unconscious; with legal implication and stayed in ICU less than 48
prognosis, treatment, and satisfaction with information given by ICU
hours were excluded in the study. ICU patient and family satisfaction
caregivers. The families in the intervention group received a family-
questionnaires were developed and validated by expert panel.
information leaflet in addition to standard information. The results
HKACCN (2004) found that: showed that family members were significantly more satisfied and
• Higher percentage of graduate nurses showed a positive effect had better comprehension of the ICU than the control group (Azoulay
on patient/ patient’s family satisfaction about the nursing care et al., 2002). In Hong Kong, many ICU nurses have participated in
they received (p = 0.03) / (p = 0.01) developing leaflets or printed information brochures about critical
• Higher percentage of nurses with formal ICU training showed illness, treatment procedure and family orientation, and have made
significant effect on patient/ patient’s family satisfaction about use of the printed information aids to facilitate patients and family
the nurses’ performance (p = 0.00)/(p = 0.05). members’ understanding of the disease process, outcomes and ICU
environment.
• *Higher nurse:patient ratio showed significant effect on patient/
patient’s family satisfaction about the nurses’ performance (p = The formal structured family meeting is another approach designed
0.00)/p = 0.07). to enhance communication in the ICU. The family meeting is an
important forum for discussion about the patient’s condition, prognosis,
Kosco and Warren, (2000) found that, “The less experienced nurses and care preferences; for listening to the family’s concerns; as well
may not be as prepared to deal with the needs of family members, as for decision making about suitable treatment goals (Gay et al.,
as nurses with more education may have more experience with 2009). Lautrette et al. (2007) conducted a randomized controlled trial
communication skills and may find it easier to keep the family in 22 ICUs in France and found that the use of a printed informational
members informed of the condition of their loved ones.” brochure with a proactive protocolized conference with families of
Though small sample sizes and or single center setting limited the patients dying in the ICU significantly lessened the prevalence and
generalizability of the aforementioned studies, they highlight areas level of family member anxiety and depression and posttraumatic
such as providing psychological support, giving information to stress.
update patient’s progress, allowing being close to the patient and Another study using a before-and-after design evaluated the effect
having comfortable hospital environment and facilities, deserve of regular, structured formal family meetings on patient outcomes
more attention by Hong Kong ICU nurses in an attempt to raise the among long-stay ICU patients. The intervention called Intensive
satisfaction with needs met of the family members of critically ill Communication System intervention, consisted of a structured formal
patients. family meeting conducted by two advance practice nurses (APN)
Recently, there was a survey to investigate the level of family within 5 days of ICU admission and weekly thereafter. Each meeting
satisfaction and to determine the factors independently associated discussed medical updates, and patient's preferences for treatment,
with higher family satisfaction was conducted by Lam et al. (2015) goals of care, and patient condition for determining effective
in the Department of Intensive Care of Pamela Youde Nethersole treatment. Despite no significant differences between control and
Eastern Hospital in Hong Kong. The response rate was 76.6% (736 intervention patients in length of stay and time to tracheostomy, the
questionnaires were collected from 961 eligible families). The total APN-facilitated family meetings increased participation of bedside
satisfaction score was 78.1 ± 14.3 (mean ± standard deviation) and nurses and social workers in the family meetings. Additionally, more
the total satisfaction score with role in decision-making was 78.6 ± time was dedicated for family meetings (Daly et al., 2010). Given that
13.6. the ICU nurse is always at the bedside engaging in communication
The results were similar to overseas findings. Concern for patients with patients and families, ICU nurses can proactively participate
and families; agitation management; family’s interaction with ward in formal structured family meeting to improve communication with
staff; impression about doctors; facilities and the intensive care unit family and in turn fulfill family informational needs.
environment were identified as independent factors associated with
Strategies to improve family satisfaction on assurance and support needs
complete satisfaction with the overall care. This survey has highlighted
that the intensive care unit environment, communication with families The use of a needs-based education program can also have an
and agitation management are the areas for improvement. impact on family satisfaction. A quasi-experimental study with pre-
and post-test design was conducted in Hong Kong ICUs to examine
Interventions to enhance family satisfaction with ICU care the effect of a needs-based education program on the anxiety
Family needs assessment levels and satisfaction of psychosocial needs of their families.
Both family members in control and intervention groups obtained
To enhance satisfaction level of family members of critically ill information about the ICU setting and practice on the first day of the
patients, family-centered care should be adopted in the ICU. Family- patient’s ICU stay. Family members in intervention group received a
centered care is an approach to care that recognizes the needs of pamphlet containing information about the ICU facilities and had two
patient’s family members plus the essential role that family members consecutive 1 hour education sessions conducted by an assigned
take part in during patient’s illness (Henneman & Cardin, 2002). nurse during the second and third day of the patient’s ICU stay. The
Studies have identified the incongruence in the perception on the content of the education program was based on the individual family
importance of family needs between families members and nurses needs assessment. Additionally, daily telephone follow up was made
(Lee et al., 2000; Maxwell et al., 2007). It is beneficial for ICU nurses to family members.
to assess the perception of family needs from a multidisciplinary care After the needs-based intervention, the family members of the
perspective, and to ensure that the plan of care is truly family care intervention group reported significantly lower levels of anxiety
based (Henneman & Cardin, 2002). Therefore, strategies to improve and higher levels of satisfaction related to information, support and
family satisfaction on information needs and assurance & support assurance needs (Chien et al., 2006).
needs as well as proximal needs are suggested for consideration.

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 Nursing Sensitive Outcome Indicators

Strategies to improve family satisfaction on proximity needs 4. System factors contributing to the displacement of tubes, lines and
drains in the ICU include all of the following except which factor?
Regarding family visitation, studies have demonstrated that patients
wish to have their family visit more frequently and families want a. Poorly secured tube/drain/line
visiting hours to be more flexible, highlighting that restrictive visitation b. Staff to patient ratio
may not fulfill families need to be close to critically ill patients (Halm &
c. Patient room location in the ICU
Tilter, 1990; Roland et al., 2001).
d. Patient positioning.
A systematic review has identified that flexible visiting policies were
associated with family members’ greater satisfaction and have the 5. According to the yearly report published by Hospital Authority in Hong
potential to reduce delirium and anxiety symptoms among patients Kong, which is NOT the commonly involved medication in medication
(Nassar Junior et al., 2018). Yet globally, flexible open visitation is not incident?
a standard of care in the ICU. The American College of Critical Care
recommends that the patient, family and nurse determine visiting a. Anti-hypertensives
schedule collectively and advocates for open visitation in adult ICU b. Known drug allergens
based on case by case (Judy et al., 2007).
c. Anticoagulants
Lee (2009) performed a quasi-experimental study in a Hong Kong
d. Dangerous drugs.
ICU to investigate the effects of contract visitation on the satisfaction
level of meeting families’ needs. Families in the intervention 6. Which of the following is NOT proved useful in improving medication
group followed a contractual visiting practice that permitted an safety in ICU?
individualized approach to family visits while the control group was
subjected to the usual restrictive practice. The results showed that a. Using computer provider order entry
families of intervention group had significantly higher satisfaction b. Using clinical decision support system
score in proximity and support need attainment.
c. Manual preparation of all parenteral infusions by bedside nurses
In summary, promoting patient and family satisfaction is a NSOI
d. Tall-man lettering in labelling look-alike medications.
that is used on an international basis to improve the quality of care
provided in the ICU. Sharing global strategies for promoting patient 7. Medication procedures in the ICU can be broken down into steps
and family satisfaction can help to enhance the ICU experience for from drug prescription, transcription, dispensing, and administration
patients, families and ICU caregivers. Internationally, nurses play procedures. How many steps have been identified in the total process?
an important role in promoting patient and family satisfaction with
ICU care. Dissemination of specific strategies that have resulted a. 10
in improved ICU care such as open visitation, family presence on b. 20
rounds, family presence during resuscitation or invasive procedures, c. 30
and other initiatives including music therapy or pet visitation in the
ICU can help to promote optimal care for patients and families in the d. 40.
ICU (Society of Critical Care Medicine, 2015).
8. Which of the following is NOT an appropriate ethical response to
medication error management?
CHECK YOUR PROGRESS
a. Be accountable to yourself and your coworkers
Assess your understanding of key points from this chapter. b. Admit when medication errors occur
c. Name, Blame, and Shame those who make serious errors.
1. Which of the following is a nurse sensitive outcome indicator? d. Avoid workarounds in medication management processes.

a. Nursing turnover rates 9. True or False: Globally, flexible open visitation is a standard of care in
b. Nursing job satisfaction rates the ICU
c. Peripheral catheter insertion rates
10. True or False: Female family members may feel the need to express
d. Pressure injury rates. grief and anger over the plight of their loved one in ICU
2. True or False: An anticipated physiologic fall is associated with
intrinsic factors such as aging, altered mental state, unsteady gait and 11. Patients falls are most accurately measured using the following units:
sensory deficits, which can be prevented by specific interventions after a. Falls per 1000 occupied bed days
assessment.
b. Average falls per admitted patient, excluding ICU

3. Which of the following is considered an extrinsic factor related to falls c. Total falls that resulted in an ICU admission
in the ICU? d. Falls per total bed capacity.

a. Patient age 12. The HKACCN study of patient and family satisfaction with nursing care
b. Patient mobility level in 3 Hong Kong ICUs should that all of the following improved satisfaction
c. Patient de-conditioning with care except?

d. ICU equipment including tubes, or drainage bags. a. High percentage of graduate nurses
b. High percentage of nurses with formal ICU training
c. High percentage of male nurses
d. High nurse: patient ratios.

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 Nursing Sensitive Outcome Indicators

Answers Camiré E, Moyen E, Stelfox HT (2009). Medication errors in critical

care: risk factors, prevention and disclosure, Canadian Medical
1. d
Association Journal 180(9), 936-43.
2. True
Canadian Association Research at the End of Life Network. (n.d.).
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4. d ca/215-family-satisfaction-survey.
5. a Centre for Health Protection (2005). Recommendations on Hospital
6. c Infection Control System in Hong Kong Scientific Committee on
Infection Control, Department of Health.
7. d
Chien WT, Chiu YL, Lam L et al. (2006). Effects of a needs-based
8. c education programed for family cares with a relative in an
9. False intensive care unit: A quasi-experimental study. International
10. True Journal of Nursing Studies 43, 39-50.
11. a Cho SH, Hwang JH, Kim J (2008). Nurse staffing and patient
mortality in intensive care units. Nurs Res 57(5), 322-30.
12. c.
Cina JL, Gandhi TK, Churchill W et al. (2006). Medication safety:
ACKNOWLEDGEMENT how many hospital pharmacy medication dispensing errors go
undetected? Journal on Quality and Patient Safety 32(2), 73-80.
The contributions of S L Tang, Wilson Lo, Ruby Wong, Tacko Tsoi, Cohen MR (2007). Medication errors. 2nd edn. Washington:
Margaret Lee, Jasmine Mak, and Tracy Fung are acknowledged. American Pharmacists Association.
Crane VS (2000). New perspectives on preventing medication
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Please read before and sign after the sit out procedure by case in-charge nurse
Yes =  No = X Not applicable = NA

Behaviors Yes/No/NA Remarks

1 Assess patient general condition whether he/she is fit

for sit out with agreement of physician

2 Adjust bed in the lower position with brakes locked,

so that it is safer for the patient to sit on and sit out
of bed

3 Educate the patient to move slowly from a lying to a

sitting or standing position to inimize dizziness and
falls due to postural hypotension

4 Provide appropriate and adequate assistance for

transfer

5 Accommodate the patient near the bed and within

eyesight of nurses for more easy observation and
detection of risk

6 Ensures the wheels of sit out chair are locked

7 Ensure all IV lines, drains and catheters in proper

position and secure well

8 Educate the patient to stay in chair until helper

arrives

9 Observe the patient's vital signs and stay with the

patient until condition stable

10 Reinforce calling for assistance

11 Arrange patient's belongings and call bell within

reach

12 Provide scope for diversional activities

13 Re-orientate patient frequently

14 Educate patient not to climb out of chair or ambulate

alone

15 Respond to patient's needs promptly

16 Invite relatives to stay with the patient if needed,

especially for patients with dementia or confusion

17 Apply safety vests and/or limb holder if necessary

For safety vests and/or limb holder(s) applied: Appendix 2. The grading and scoring system for applying restraint in ICU
18 Ensure the safety vests and/or limb holder is in the (Tuen Mun Hospital, Hong Kong)
proper position and functioning well

19 Explain the need for restraint to the patient and gain

his/her cooperation

20 Perform close observation of patient after applying

restraint equipment and document properly

21 Inform the physician of reasons for restraint

22 Inform relatives/significant others as soon as possible

Name of nurse: Signature: Date: Time:

Appendix 1. ICU checklist for sitting patient out of bed (from: Tuen Mun
Hospital, Hong Kong)

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Appendix 3. Self-report form

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 Nursing Sensitive Outcome Indicators

Date: Duty shift:  AM  PM  N Support Worker/Coordinator to complete – Incident Analysis

Case  Incorrect client  Request by a client/care to not give

nurse  Incorrect medicine medication

Error  Incorrect dose  Breach of the Organization policy and

identified guidelines
 Incorrecttime
 Client refuses medication
Residents  Incorrect route
involved  Incorrect storage of medications
 Split or dropped medicine
 Incorrect supply of medications from the
• wrong drug • wrong abbreviation  Out of date medicine pharmacy
• wrong dosage form • wrong instruction  Missing medicine  Other (describe)
• wrong strength/ • wrong patient  Lack of documentation such as
Prescribing dosage • double entry assessment, medication order, medication
• wrong duration support plan, medication record sheet (if
• drug omission
required)
• wrong frequency • known drug allergy
• wrong route Coordinator to complete - Incident Analysis Conclusions

• wrong drug • wrong drug What, if anything could have Describe:

prevented the incident?
• wrong dosage form • wrong dosage form
• wrong strength/ • wrong strength/
dosage dosage
Type
of error • wrong quantity • wrong quantity
Was the incident related to a  Yes Comment:
(circle all Dispensing • known drug allergy • known drug allergy procedure breakdown (staffs
 No
that apply) • wrong patient focus)?

• wrong label
information
• double dispensing Was the incident related to  Yes Comment:
the medication management
• drug omission  No
system (prescription, supply,
• wrong drug • wrong iv diluent documentation focus)?

• wrong dosage form • wrong time

• wrong dose • extra dose Was the immediate action  Yes Comment:
Administration taken appropriate?
• wrong flow rate • dose omission  No
• wrong patient • unordered drug
• wrong route/method • known drug allergy

When did this occur? Date/s Time/s Coordinator to Complete - Action Plan

Insert further actions as required Who By when Date

completed
When was the incident Date/s Time/s
identified? Analysis completed

Describe the medication

incident of error Follow up with staff member/s

Possible reason(s) for

incident Coordinator to Complete – Closure

Evaluation (if appropriate, describe how action/improvements were evaluated and the result):
Immediate action taken

Reported by Signed

Supervisor notified (name/rank): Date/time:

Yes No
Outcome or end result: (tick applicable boxes)
 Issue resolved – no improvements implemented
Doctor notified (name/rank): Date/time:
Yes No  Improvement implemented (describe):

Pharmacist notified: Date/time:

Yes No
Closed Out/Complete:
Next of kin notified: Date/time:
Yes No

Treatment ordered by doctor/pharmacist

(name/rank): Coordinator’s Signature: Date:

Appendix 4. Medication incident report form

139