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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.116_slideshow.ppt
February 01, 2006 - Effective shift handover: a literature review. Health and Safety Executive. June 1996. … Offshore technology report-OTO 96 003. … Shift changes among emergency physicians: best of times, worst of times. … Emergency Department Transitions
May occur at bedside or in remote location
May be interactional or … =15051706
Case (cont.): Lost in Transition
Four hours after arrival, the lab called the ED to report
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psnet.ahrq.gov/issue/2009-national-patient-safety-goals
August 03, 2016 - March 8, 2017
Learning from different lenses: reports of medical errors in primary care … July 27, 2022
Association of patient and family reports of hospital safety climate with … March 21, 2007
Detection and prevention of medication errors using real-time bedside … September 28, 2022
Shift-to-shift nursing handover interventions associated with … May 1, 2019
Using Kotter's change model for implementing bedside handoff: a quality improvement
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psnet.ahrq.gov/issue/silent-witnesses-faculty-reluctance-report-medical-students-professionalism-lapses
March 10, 2021 - Silent Witnesses: Faculty Reluctance to Report Medical Students' Professionalism Lapses. … Silent Witnesses: Faculty Reluctance to Report Medical Students' Professionalism Lapses. … Qualitative analysis exploring the functions of questions during end of shift handoffs. … December 7, 2005
Patient reports of preventable problems and harms in primary health … December 2, 2015
Bedside shift-to-shift handoffs: a systematic review of the literature
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psnet.ahrq.gov/issue/safety-culture-building-and-sustaining-cultural-change-aviation-and-healthcare
May 04, 2005 - Report IV. … March 6, 2005
Training Program for Nurses on Shift Work and Long Work Hours. … Final Report. … March 17, 2021
A dynamic risk management approach for reducing harm from invasive bedside … September 30, 2023
CHPSO Annual Reports.
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psnet.ahrq.gov/issue/ins-and-outs-change-shift-handoffs-between-nurses-communication-challenge
October 19, 2022 - Study
The ins and outs of change of shift handoffs between nurses: a communication … The ins and outs of change of shift handoffs between nurses: a communication challenge. … The ins and outs of change of shift handoffs between nurses: a communication challenge. … August 21, 2019
Using incident reports to assess communication failures and patient outcomes … July 12, 2017
Using Kotter's change model for implementing bedside handoff: a quality
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psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-and-performance
April 24, 2024 - metric tracking through dashboards; and (3) ongoing and real-time data literacy training to enhance bedside … Efficient communication and shared responsibility for patient outcomes between daytime and evening shift … It fosters performance data report comprehension in about 15 minutes in day-to-day casual conversation … Efficient communication and shared responsibility for patient outcomes between daytime and evening shift … Both IT and clinical staff should share a common understanding of needed EHR fields, and report outputs
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psnet.ahrq.gov/issue/teamstepps-canada
July 29, 2020 - October 11, 2017
Shift to Safety. … Results
February 5, 2020
Diagnostic Strategy for the COVID-19 Pandemic – Bench to Bedside … November 29, 2023
Training Program for Nurses on Shift Work and Long Work Hours. … Analysis of incident reports from a patient safety organization. … or alongside emergency departments: incorporating realist methodology into patient safety incident report
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psnet.ahrq.gov/primer/nursing-and-patient-safety
September 07, 2019 - Nurses are a constant presence at the bedside and regularly interact with physicians, pharmacists, families … Nurse staffing and patient safety Nurse staffing ratios Nurses' vigilance at the bedside is essential … Determining adequate nurse staffing is a very complex process that changes on a shift-by-shift basis. … The process of establishing nurse staffing on a unit-by-unit and shift-by-shift basis is discussed in … Can nurses’ shift work jeopardize the patient safety? A systematic review.
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psnet.ahrq.gov/issue/patient-preferences-participation-patient-care-and-safety-activities-hospitals
September 13, 2023 - January 4, 2012
Bedside handover: quality improvement strategy to "transform care at … the bedside." … June 14, 2023
Dynamic pocket card for implementing ISBAR in shift handover communication … June 16, 2010
The association of shift-level nurse staffing with adverse patient events … December 9, 2020
Student mistakes and teacher reactions in bedside teaching.
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psnet.ahrq.gov/issue/limiting-nurse-overtime-and-promoting-other-good-working-conditions-influences-patient-safety
July 20, 2005 - April 15, 2009
How useful are voluntary medication error reports? … August 13, 2008
Improving patient safety—five years after the IOM report. … June 8, 2016
Effect of social influences on pharmacists' intention to report adverse … October 17, 2007
Improving patient safety by repeating (read-back) telephone reports … June 13, 2018
From the flight deck to the bedside: core aviation concepts applied to
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psnet.ahrq.gov/issue/influence-workplace-demands-nurses-perception-patient-safety
August 09, 2006 - January 7, 2015
Nursing bedside clinical handover—an integrated review of issues and … October 27, 2010
The Veterans Affairs shift change physician-to-physician handoff project … August 28, 2019
The courage to speak out: a study describing nurses' attitudes to report … 14, 2019
Nurses' safety motivation: examining predictors of nurses' willingness to report … August 7, 2019
Does a unit shift report "blackout" period improve patient safety?
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psnet.ahrq.gov/issue/implementation-evidence-based-extubation-checklist-reduce-extubation-failure-patients-trauma
March 07, 2018 - March 30, 2016
Qualitative content analysis of coworkers' safety reports of unprofessional … October 15, 2014
Association of coworker reports about unprofessional behavior by surgeons … January 31, 2024
Student mistakes and teacher reactions in bedside teaching. … September 9, 2009
Ten years after the IOM report: engaging residents in quality and patient … Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside
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psnet.ahrq.gov/issue/nursing-2006-patient-safety-survey-report
March 01, 2023 - Patient-safety survey report. Nursing. 2006;36(5):54-64. … February 10, 2021
Barriers to and facilitators of bedside nursing handover: a systematic … December 15, 2021
Training Program for Nurses on Shift Work and Long Work Hours. … October 10, 2021
Shift-to-shift nursing handover interventions associated with improved … June 5, 2019
Using incident reports to assess communication failures and patient outcomes
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psnet.ahrq.gov/issue/another-fatal-failure-kingdrew
May 03, 2017 - This article reports on a death that occurred at the Martin Luther King Jr. … Incorporating Health Information Technology Into Workflow Redesign: Request for Information Summary … Report. … April 17, 2019
Does a unit shift report "blackout" period improve patient safety? … October 22, 2014
Bedside shift reports: what does the evidence say?
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psnet.ahrq.gov/issue/longer-shifts-hospital-nurses-higher-levels-burnout-and-patient-dissatisfaction
August 15, 2012 - September 13, 2017
Hospital staff nurses' shift length associated with safety and quality … December 12, 2012
Bachelor's degree nurse graduates report better quality and safety … October 20, 2021
Training Program for Nurses on Shift Work and Long Work Hours. … November 18, 2020
The radiology impact of healthcare errors during shift work. … August 31, 2016
Using Kotter's change model for implementing bedside handoff: a quality
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psnet.ahrq.gov/web-mm/other-hand
September 01, 2006 - During the night shift, the midnight BP measurement using the right arm revealed a very low pressure … Methods of alerting the bedside practitioner are promising, yet they introduce new safety concerns. … The use of any bedside or applied patient alert (e.g., allergy bracelets, overhead signs, tattoos) relies … Allow time for a comprehensive report at nursing change of shift and during physician "hand-offs." … April 6, 2016
Training Program for Nurses on Shift Work and Long Work Hours.
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psnet.ahrq.gov/issue/effects-nursing-rounds-patients-call-light-use-satisfaction-and-safety
April 19, 2006 - They found that implementation of specific actions in frequent nursing bedside rounds reduced patient … consecutive 12-hour shifts on cognition, sleepiness, and domains of nursing performance in day and night shift … May 18, 2005
Effect of social influences on pharmacists' intention to report adverse … The relationship between patient safety culture and the intentions of the nursing staff to report … November 7, 2012
Barriers to and facilitators of bedside nursing handover: a systematic
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psnet.ahrq.gov/periodic-issue/periodic-issue-409
September 27, 2023 - issue highlights what's new this week in patient
safety literature, news, conferences, reports … Diagnostic errors were associated with longer interpretation times, higher shift volume, and weekend … are also summarized, ranging from low-cost measures such as breaks for physical activity during the shift … victims and fear of the peers who knew of the situation and were not psychologically safe enough to report … Before discharge, medications intended for home use were delivered to the patient’s bedside, but the
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psnet.ahrq.gov/issue/clinical-issues-series
July 05, 2006 - May 18, 2005
Bringing change-of-shift report to the bedside: a patient- and family-centered … October 15, 2014
Bedside shift reports: what does the evidence say?
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psnet.ahrq.gov/issue/why-patient-summaries-electronic-health-records-do-not-provide-cognitive-support-necessary
July 25, 2012 - November 16, 2022
The content and context of change of shift report on medical and surgical … November 29, 2023
Diagnostic errors and the bedside clinical examination. … July 12, 2017
Using Kotter's change model for implementing bedside handoff: a quality … June 15, 2016
Bedside shift reports: what does the evidence say?