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Total Results: 376 records

Showing results for "bedside shift report".

181. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49810/psn-pdf
     November 01, 2017 - On the night shift, the bedside nurse went to see the patient at 3:00 AM to administer the next scheduled … He died peacefully with his family at the bedside. … adequate documentation convey the crucial information to everybody on the care team, including the night 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

182. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49635/psn-pdf
     September 01, 2011 - Before leaving, she prepared a new bottle of lipids and left it at the bedside, as the current bottle … The problem was not discovered until the nurses on the next shift made rounds and checked the patient's … Numerous reports have documented unintentional failures to connect the correct tubing between intravenous … tubing connection is a routine, familiar, and common task in nursing, often performed many times on one shift … Readers should not interpret any statement in this report as an official position of AHRQ or of the

183. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49723/psn-pdf
     January 01, 2015 - Traditionally, FHR monitors were analog devices located at the patient's bedside.(5) Signals were traced … Previously when FHR tracings occurred only at the bedside, a nurse or physician would have to visit … the bedside frequently, and it was not possible to continuously monitor all patient tracings for signs … The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal … Readers should not interpret any statement in this report as an official position of AHRQ or of the

184. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49583/psn-pdf
     April 01, 2009 - The night shift nurse continued the infusion at this rate, as did the nurse on the following day shift … The day shift nurse was curious about the low dose and queried the intern, but the nurse was distracted … networks will help to maximize the value of electronic system double checks in the pharmacy and at the bedside … Safe Practices for Better Healthcare: 2009 Update: A Consensus Report. [Available at] 14. … SentinelEvents/Statistics/ http://www.ncbi.nlm.nih.gov/pubmed/15465961 http://www.qualityforum.org/publications/reports

185. In Conversation With… Maureen Bisognano | PSNet
     psnet.ahrq.gov/perspective/conversation-maureen-bisognano
     February 26, 2025 - It was well before the publication of the IOM reports on safety and quality. … It was a shift from a sense of seeing events as only very rare lapses to seeing the whole system. … And they very much took their eye off the ball of what was happening at the bedside. … attention to the little everyday events (like a unit that doesn't have enough staffing on the night shift … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S

186. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/857259/psn-pdf
     November 30, 2023 - barcode label and administered about 8 ounces of the dialysis liquid orally before the end of her shift … https://psnet.ahrq.gov/issue/medical-error-third-leading-cause-death-us https://psnet.ahrq.gov//#2 bedside … , where one individual hands off a medication to another for administration, either at a change of shift … that medications are verified by a pharmacy staff member before a replacement label is issued for the bedside … Readers should not interpret any statement in this report as an official position of AHRQ or of the

187. Infused, Not Ingested | PSNet
     psnet.ahrq.gov/web-mm/infused-not-ingested
     February 01, 2017 - The Commentary Medication errors by nurses occur frequently, largely due to their bedside role in patient … floating” and the underlying challenge of assuring staff competence, and (ii) the nurse’s failure to report … Workers’ reluctance to report errors may stem from a punitive work environment and the stigma that error … Take-Home Points Due to their proximity at the bedside, nurses are frequently involved in medication … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S

188. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49819/psn-pdf
     February 01, 2018 - After discussions with her family, care was withdrawn, and she died with her family at her bedside. … Handoffs occur in the hospital every time providers change shift and whenever a patient changes locations … improvement was accomplished without any time cost; resident time conducting handoffs, time at the bedside … Adapting the I-PASS handoff program for emergency department inter-shift handoffs. … Readers should not interpret any statement in this report as an official position of AHRQ or of the

189. Medication Mix-Up Leads to Patient Death | PSNet
     psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
     July 08, 2022 - new barcode label and administered about 8 ounces of the dialysis liquid orally before the end of her shift … need for improvement, and how serious medication errors can occur despite obvious “red flags” at the bedside … hand-off, where one individual hands off a medication to another for administration, either at a change of shift … that medications are verified by a pharmacy staff member before a replacement label is issued for the bedside … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S

190. Monitoring Fetal Health | PSNet
     psnet.ahrq.gov/web-mm/monitoring-fetal-health
     September 08, 2010 - Traditionally, FHR monitors were analog devices located at the patient's bedside.( 5 ) Signals were traced … Previously when FHR tracings occurred only at the bedside, a nurse or physician would have to visit the … bedside frequently, and it was not possible to continuously monitor all patient tracings for signs of … The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S

191. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50842/psn-pdf
     January 29, 2020 - The next day, the night shift RN discovered the child had another patient’s identification (ID) band … A qualitative analysis performed on 227 RCA (root cause analysis) reports from the Veterans Health Administration … To improve communication between the ED and CT suite, a cultural shift away from using room numbers to … Technological advances, such as point-of-care 2D barcode scanning, use of workstations on wheels (WOWs) at the bedside … Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports

192. The Hazards of Distraction: Ticking All the EHR Boxes | PSNet
     psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
     April 09, 2014 - her brain (done for cancer staging) showed a right subdural hematoma with a very small (5 mm) midline shift … The patient was alert and oriented when she arrived in the ED, but she did report falling and hitting … On that study, the radiologist noted that the subdural hematoma had enlarged and the midline shift had … Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a … Checking it twice: an evaluation of checklists for detecting medication errors at the bedside

193. Eptifibatide Epilogue | PSNet
     psnet.ahrq.gov/web-mm/eptifibatide-epilogue
     March 04, 2011 - The night shift nurse continued the infusion at this rate, as did the nurse on the following day shift … The day shift nurse was curious about the low dose and queried the intern, but the nurse was distracted … networks will help to maximize the value of electronic system double checks in the pharmacy and at the bedside … Safe Practices for Better Healthcare: 2009 Update: A Consensus Report. [Available at] 14. … June 16, 2019 ISMP medication error report analysis.

194. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33787/psn-pdf
     January 01, 2018 - It was well before the publication of the IOM reports on safety and quality. … It was a shift from a sense of seeing events as only very rare lapses to seeing the whole system. … And they very much took their eye off the ball of what was happening at the bedside. … attention to the little everyday events (like a unit that doesn't have enough staffing on the night shift … So we're very focused on keeping that connection between the boardroom and the bedside tight.

195. Central, not Epidural | PSNet
     psnet.ahrq.gov/web-mm/central-not-epidural
     August 28, 2024 - Before leaving, she prepared a new bottle of lipids and left it at the bedside, as the current bottle … The problem was not discovered until the nurses on the next shift made rounds and checked the patient's … Numerous reports have documented unintentional failures to connect the correct tubing between intravenous … tubing connection is a routine, familiar, and common task in nursing, often performed many times on one shift … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S

196. PowerPoint Presentation (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.398_slideshow.ppt
     February 01, 2017 - an MRI of her brain (done for cancer staging) showed a right subdural hematoma with a 5 mm midline shift … The patient was alert and oriented when she arrived in the ED, but she did report falling and hitting … On that study, the radiologist noted that the subdural hematoma had enlarged and the midline shift had … Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a

197. In Conversation With… Jack Needleman, PhD | PSNet
     psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
     September 01, 2012 - research you've done but also your evaluation of the Robert Wood Johnson "Transforming Care at the Bedside … RW : From your work in evaluating "Transforming Care at the Bedside," what did you learn about the bedside … onto a med–surg unit has 4 to 8 patients assigned, each of whom has a to-do list at the start of the shift … need to make sure that they're able to meet the nursing needs of those patients every day of their shift … This report will compile a wide range of data on the nursing workforce.

198. Palliative Care: Comfort vs. Harm | PSNet
     psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
     December 04, 2016 - On the night shift, the bedside nurse went to see the patient at 3:00 AM to administer the next scheduled … He died peacefully with his family at the bedside. … adequate documentation convey the crucial information to everybody on the care team, including the night shift … 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

199. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49821/psn-pdf
     February 01, 2018 - Studies of ADC-related errors report on diverse patient populations with various control factors and … and barcode-assisted medication administration (BCMA) can provide yet another check at the patient bedside … These actions remove some of the possible errors that can occur in the process of bedside decision-making … Share and provide feedback on medication incident reports and experiences. … Readers should not interpret any statement in this report as an official position of AHRQ or of the

200. Application of Safety-II Principles | PSNet
     psnet.ahrq.gov/perspective/application-safety-ii-principles
     August 28, 2024 - system and recognition of the importance of evaluating successes in addition to failures yielded a shift … We have conducted learning teams on early ambulation, bedside medications, oxygen safety, and care of … However, as we shift our culture, we have also shifted to referring to great catches and patient care … Anything we can do to enhance learning and bring the walls down, such as a shift in language, is what … If you ask registration, perioperative techs, or bedside nurses, you'll hear about things that folks