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psnet.ahrq.gov/node/49536/psn-pdf
May 01, 2007 - During the night shift, the midnight BP measurement using the right arm revealed a very low pressure … paper and electronic) are often inaccessible to the clinician providing care to
the patient at the bedside … 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."
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psnet.ahrq.gov/node/865540/psn-pdf
April 11, 2024 - During nursing shift change, the incoming nurse was told that the NG tube was ready for use. … of closed loop communication between the physician and the
nurse, and between nurses at change of shift … communication
between the provider and initial nurse, inaccurate information was conveyed to the oncoming shift … Readers should not interpret any statement in this report as an official position of AHRQ or
of the … authors has any affiliation or financial
involvement that conflicts with the material presented in this report
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psnet.ahrq.gov/issue/risk-and-event-assessment
August 12, 2020 - November 24, 2010
Bringing change-of-shift report to the bedside: a patient- and family-centered
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psnet.ahrq.gov/issue/perinatal-patient-safety-and-quality
January 19, 2022 - July 6, 2011
Bringing change-of-shift report to the bedside: a patient- and family-centered
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psnet.ahrq.gov/issue/partnering-patients-and-families-enhance-safety-and-quality-mini-toolkit
September 12, 2018 - January 27, 2012
Bringing change-of-shift report to the bedside: a patient- and family-centered
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psnet.ahrq.gov/issue/symposium-simulation-science-health-and-medicine
April 03, 2017 - April 3, 2017
Bringing change-of-shift report to the bedside: a patient- and family-centered
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.188_slideshow.ppt
November 01, 2008 - Spotlight Case [MONTH] 2003
Spotlight Case November 2008
Dangerous Shift
Source and Credits … changes
Understand the limits of standardizing handoffs in preventing errors at shift change
Explain … This transfer happened to coincide with a shift change for both the nursing staff and the physicians … Case: Dangerous Shift (2)
The off-going nurse assumed the transfer would take place immediately and … Approximately 45 minutes later, the unit clerk called the infant’s bedside nurse to report that the infant
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psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-useful-tool-risk-identification-and-injury-prevention
September 24, 2010 - May 10, 2013
A safe haven for nurses to report medication errors? … April 7, 2010
View More
Related Resources
Does a unit shift report … April 10, 2019
Implementing bedside handoff in the emergency department: a practice improvement
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psnet.ahrq.gov/issue/safe-handover
December 21, 2017 - View More
Related Resources
Innovative approach to reconstruct bedside … May 31, 2017
Patient handoffs: is cross cover or night shift better? … January 18, 2017
The most crucial half-hour at a hospital: the shift change. … November 4, 2015
Transfer of accountability: transforming shift handover to enhance patient
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psnet.ahrq.gov/issue/health-it-implementation-stories-hands-care-plan-tool-seeks-improve-nurse-communication
December 24, 2008 - August 21, 2019
Using Kotter's change model for implementing bedside handoff: a quality … February 4, 2011
The content and context of change of shift report on medical and surgical
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psnet.ahrq.gov/issue/people-are-more-error-prone-after-committing-error
June 29, 2011 - July 20, 2022
Bedside shift-to-shift handoffs: a systematic review of the literature. … September 11, 2024
Care home safety incidents and safeguarding reports relating to hospital
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psnet.ahrq.gov/issue/evaluation-problem-specific-sbar-tool-improve-after-hours-nurse-physician-phone-communication
December 30, 2014 - Annual Perspective: Topics in Medication Safety
March 31, 2022
Using incident reports … December 30, 2014
Bedside shift reports: what does the evidence say? … December 19, 2014
Task uncertainty and communication during nursing shift handovers.
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psnet.ahrq.gov/issue/nursing-peer-review-developing-framework-patient-safety
January 15, 2020 - December 12, 2018
Bringing change-of-shift report to the bedside: a patient- and family-centered
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psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-and-performance
September 23, 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/node/49607/psn-pdf
August 01, 2010 - At the beginning of a new shift, the oncoming nurses listen to the
taped report for each patient in … The nurse made rounds on each of the patients for whom she had a report at the beginning of the shift … Near the end of the shift, the nurse recorded a report on
her four patients. … At the end of the shift, the charge nurse asked why there wasn't a taped report on the fifth
assigned … Incorporating bedside reporting into change-of-shift report. Rehabil Nurs.
2010;35:70-74.
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psnet.ahrq.gov/node/49642/psn-pdf
December 01, 2011 - The literature on the widespread adoption comes largely from news stories and
market research reports … physicians using an iPad spent
39 minutes less at a computer workstation per 8-hour emergency department shift … e.g., remote telemetry monitoring) as well as patient devices (e.g.,
pacemakers).(17) Although such reports … investigating the possibility of providing mobile devices to health care workers that can be checked out
for a shift … Report: 94 percent of docs have smartphones, but communication gaps persist.
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psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety
May 01, 2012 - Arguably the bedside is the most important situation for the physician to perceive and understand. … Workflow must be redesigned to ensure adequate time for bedside assessments. … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S … authors has any affiliation or financial involvement that conflicts with the material presented in this report … February 19, 2013
Professionalism in the era of duty hours: time for a shift change?
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psnet.ahrq.gov/issue/patient-handoffs-0
November 23, 2024 - January 18, 2017
Bedside shift reports: what does the evidence say?
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psnet.ahrq.gov/issue/medication-safety-operating-room-survey-preparation-methods-and-drug-concentration
December 22, 2018 - of medications administered by anesthesiologists in 2012 were still prepared by the provider at the bedside … Related Resources From the Same Author(s)
Medication errors in pediatric anesthesia: a report … May 27, 2011
Medication administration in anesthesia: time for a paradigm shift.
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psnet.ahrq.gov/issue/guide-patient-and-family-engagement-hospital-quality-and-safety
December 24, 2008 - clinicians and patients, the guide emphasizes four strategies—working with patients as advisors, improving bedside … communication, integrating patients and families into shift changes, and using patient input to improve … December 18, 2008
Eliminating CAUTI: Interim Data Report: A National Patient Safety Imperative