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psnet.ahrq.gov/issue/medical-device-associated-safety-and-risk-surveillance-and-stratagems
March 06, 2005 - March 28, 2018
Using Kotter's change model for implementing bedside handoff: a quality … consecutive 12-hour shifts on cognition, sleepiness, and domains of nursing performance in day and night shift … April 3, 2019
The "hemolyzed" physical examination—situational challenges to accurate bedside
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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
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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
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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
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psnet.ahrq.gov/node/33742/psn-pdf
December 01, 2012 - No one even understood what it was, how you recognized it at the bedside, what
patients were vulnerable … In terms of recognizing it at the
bedside, you really do need to do some formal cognitive testing even … All these little things happen on the night shift because it's when things are otherwise
quieter. … have to do major room switches, if someone comes up VRE or MRSA positive, they
often do them on night shift … But right now the only way to reliably identify
the delirium is from someone going to the bedside.
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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
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psnet.ahrq.gov/perspective/conversation-chalapathy-venkatesan-and-kathy-helak-about-application-safety-ii
August 28, 2024 - 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 … system and recognition of the importance of evaluating successes in addition to failures yielded a shift
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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
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psnet.ahrq.gov/periodic-issue/periodic-issue-380
March 15, 2023 - issue highlights what's new this week in patient
safety literature, news, conferences, reports … Book/Report
Access to Clinical Information at the Bedside. … Report no. 22-01363-52. … The bedside and charge nurses had difficulty placing the NGT and the X-ray confirmation was not done. … and treating acute agitation secondary to delirium, and the importance of clear communication during shift
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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.
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psnet.ahrq.gov/perspective/conversation-abraham-verghese-md
November 01, 2012 - As we come to the bedside more, we will in a sense come together from both ends. … Examination as a Patient Safety Practice
November 1, 2012
Perspective
Near the end of his shift … laboratory tests, electrocardiograms, cross-sectional body images, endoscopic findings, microscopic reports … 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
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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
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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
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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
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psnet.ahrq.gov/perspective/evidence-based-physical-examination-patient-safety-practice
November 01, 2012 - Endnote tagged PubMedId RIS
Download Citation
Perspective
Near the end of his shift … laboratory tests, electrocardiograms, cross-sectional body images, endoscopic findings, microscopic reports … As we come to the bedside more, we will in a sense come together from both ends. … 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
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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.
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psnet.ahrq.gov/node/49724/psn-pdf
January 01, 2015 - The night resident was called to the patient's bedside multiple times overnight
by the charge nurse … The patient remained in sustained pain and the surgical team was called to the bedside multiple times … what needs to be done at different stages), address some of the issues that invariably arise with 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/node/866395/psn-pdf
July 23, 2024 - of the Innovation
The Institute for Healthcare Policy and Innovation at the University of Michigan reports … injury, deterioration following issues with
postoperative fluid management, and decompensation during bedside … This shift in mindset can
promote patient safety.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.338_slideshow.ppt
January 01, 2015 - The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal … The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal … 18757666
8
Remote Monitoring of FHR
Traditionally, FHR monitors have been located at the patient's bedside … The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal … that it facilitates monitoring of all patients at once
Previously, a nurse or physician had to visit bedside
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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