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Keeping Patients Safe: Transforming the Work Environment of Nurses
dure and provide prompts to clinicians that identify appropriate clinical interventions in response to individualized patient characteristics or clinical developments. Clinical pathways are often evidence-based and are typically multidisciplinary—specifying the responsibilities of nurses, physicians, and other members of the health care team. They sometimes are a component of or replace documentation in the chart and may be paper-based or automated. Most clinical pathways are locally developed—frequently within a hospital—serving both cost-containment and quality assurance purposes (Trowbridge and Weingarten, 2001a). There is evidence that they are increasingly being used to manage and standardize both nursing care processes and interdisciplinary care in hospitals (Anonymous, 2001; Bridgeman et al., 1997; Helfrich Jones et al., 1999; Schriefer and Botter, 2001).
The AHRQ evidence-based report Making Health Care Safer: A Critical Analysis of Patient Safety Practices cites conflicting evidence on the efficacy of clinical pathways in influencing provider behavior and patient safety (Trowbridge and Weingarten, 2001a). However, experts on mechanisms for promoting interdisciplinary collaboration point out that such care delivery protocols and care maps equate to the use of standard operating procedures that are useful in other high-risk environments. These prewritten documents assist team members in providing consistent quality care while ensuring that other team members know what is occurring with the patient. They also facilitate the assumption of care by team members if the lead person is unable to carry out his or her responsibilities (Ingersoll and Schmitt, 2003).
Computer-supported clinical decision support systems Clinical decision support systems (CDSSs) assist clinicians in applying new information to patient care through the analysis of patient-specific clinical variables. They vary in complexity, function, and application. Some but not all are computer-based. Crossing the Quality Chasm (IOM, 2001a) highlights the potential of automated CDSSs—software that integrates information on the characteristics of individual patients with a computerized knowledge base for the purpose of generating patient-specific assessments or recommendations designed to aid clinicians or patients in making clinical decisions. The AHRQ evidence-based report Making Health Care Safer: A Critical Analysis of Patient Safety Practices notes that the preponderance of evidence suggests that CDSSs are at least somewhat effective, especially with respect to the prevention of medical errors (Trowbridge and Weingarten, 2001b). CDSSs are widely implemented and evaluated with respect to physician practice, but less so in nursing.
Point-of-care decision support devices can be mobile, stationary, or hand-held. They allow nurses to gather patient information (e.g., on allergies, intake restrictions) automatically from patient records or from data