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psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
August 01, 2006 - In the morning his bedside nurse for the day came in and stated that she would be giving him his fourth … A national trend, in place for more than a decade, has resulted in a shift in the setting in which chemotherapy … The shift of oncology inpatient care to outpatient care: the challenge of retaining expert oncology nurses … 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/peripheral-iv-too-long
September 15, 2011 - The bedside nurse asked the covering physician if the peripheral IV could be extended for an additional … documentation to include the date of peripheral IV insertion and a description of the site during each 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 … January 27, 2021
Impact of structured interdisciplinary bedside rounding on patient outcomes
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psnet.ahrq.gov/node/33803/psn-pdf
January 01, 2015 - The 2014 report showed progress in a variety of areas—most notably access
to care. … As noted in the recent IOM report, we don't yet have good measures of diagnostic accuracy. … and Safety focuses on four
https://psnet.ahrq.gov/issue/national-healthcare-quality-and-disparities-reports … Third, enhancing continuity of care by keeping the patient and family
informed through nurse bedside … change-of-shift reports, assuring that during shift changes it is not simply
one nurse talking with
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psnet.ahrq.gov/issue/cultural-transformation-toward-patient-safety-one-conversation-time
November 16, 2022 - Surgical residents, duty hours restrictions, and shift transitions. … July 20, 2022
WebM&M Cases
Failure to Report
March … July 1, 2008
Letter
In response to "Failure to Report … across eight hospitals: who reports what about whom? … Diagnostic Failure: The Growing Deficit
February 1, 2019
Implementing bedside
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psnet.ahrq.gov/node/865655/psn-pdf
April 24, 2024 - The patient was discharged that afternoon despite continuing to report extreme pain. … Diagnosis
Historically, CS has been diagnosed by bedside assessment using various clinical signs and … Did resident duty hours or shift work play a role in the delayed diagnosis, and if so, how? … In addition, we recommend concurrent bedside patient examination of patients
who are being evaluated … 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/issue/fatal-case-iatrogenic-hypercalcemia-after-calcium-channel-blocker-overdose
October 26, 2022 - This case report documents an adverse event that resulted from treatment intended to reverse the effects … August 31, 2016
Implementation of a modified bedside handoff for a postpartum unit. … January 11, 2017
Identifying health information technology related safety event reports … from patient safety event report databases. … January 18, 2017
Sleep deprivation and error in nurses who work the night shift.
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psnet.ahrq.gov/node/74713/psn-pdf
January 26, 2022 - When the morning shift started, the new
nursing assistant called the team to bedside as the patient … repeat opioid dosing in a narrow
period of time may not relieve the patient’s pain and can dramatically 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/innovation/lifepoint-national-quality-program-provides-structured-framework-reducing-inpatient-harm
February 26, 2025 - can easily be replicated across hospitals (e.g., TeamSTEPPS, the use of interdisciplinary care teams, bedside … shift reports, prioritizing patient engagement) and providing guidance on how to implement and master
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psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-compartment-syndrome-after-lower-leg-fracture
November 25, 2020 - The patient was discharged that afternoon despite continuing to report extreme pain. … Diagnosis Historically, CS has been diagnosed by bedside assessment using various clinical signs and … Did resident duty hours or shift work play a role in the delayed diagnosis, and if so, how? … In addition, we recommend concurrent bedside patient examination of patients who are being evaluated … 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/web-mm/mismanagement-delirium
February 13, 2014 - loved one's care and requested alternate ward placement that allowed a 24-hour family caregiver at the bedside … The patient continued to act out dreams, but having a family caregiver at the bedside prevented escalation … 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/49527/psn-pdf
December 01, 2006 - As it was the change of nursing shift, the bedside nurse for the patient was not available and there … Classifying laboratory incident reports to identify
problems that jeopardize patient safety. … Direct interfacing of LIS to electronic medical record with
elimination of printed reports. … 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/web-mm/right-patient-wrong-sample
June 01, 2004 - As it was the change of nursing shift, the bedside nurse for the patient was not available and there … Classifying laboratory incident reports to identify problems that jeopardize patient safety. … Direct interfacing of LIS to electronic medical record with elimination of printed 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/periodic-issue/periodic-issue-275
January 29, 2021 - issue highlights what's new this week in patient
safety literature, news, conferences, reports … The shift to in situ training identified several latent safety threats (e.g., equipment access, lack … shares the author’s frustrations with the system of care observed during an overnight visit at the bedside … Book/Report
Textbook of Patient Safety and Clinical Risk Management.
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psnet.ahrq.gov/node/49801/psn-pdf
August 01, 2017 - Bedside evaluation revealed she was hypotensive
(blood pressure 75/45 mm Hg), tachycardic (heart rate … The intensive care unit (ICU) team consulted at the bedside and made plans to transfer her to the ICU … Early warning scores use risk prediction,
typically generated each shift, based on vital signs and information … Natl Health Stat Report. 2010;29:1-20, 24. [go to PubMed]
3. … 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/issue/optimizing-medication-reconciliation-and-transitions-care-insights-pharmacist-and-pharmacy
July 25, 2023 - Review into the Quality of Care and Treatment Provided by 14 Hospital Trusts in England: Overview Report … November 24, 2021
National Healthcare Quality and Disparities Report Chartbook on Patient … March 8, 2023
Eliminating CAUTI: Interim Data Report: A National Patient Safety Imperative … February 20, 2008
Diagnostic Strategy for the COVID-19 Pandemic – Bench to Bedside to
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psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
June 01, 2005 - If an article reports improvements in these ranges, scrutinize it closely. … There is a dichotomy—some quality experts are far removed from the bedside. … Their theories, which are often very elegant, are just not always applicable to bedside reality. … One real benefit that physicians working in this area bring is that we still practice at the bedside, … As a matter of fact, the goal is to put my team out of business—to shift the work to the caregivers at
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psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
September 30, 2020 - Abnormal findings should trigger more thorough bedside evaluation, including history-taking and physical … An alert with the institution's protocol for abnormal obstetric vital signs could help prompt urgent bedside … Obstet Gynecol . 2015;126:155–62. [ Free full text ] R 3 Report – Requirement, Rationale, Reference … The Joint Commission. [ Available at ] R 3 Report: Provision of Care, Treatment, and Services standards … 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/node/852700/psn-pdf
August 30, 2023 - engagement, and feeling valued, as
well as attrition from jobs and healthcare professions, and a shift … One trend that I hope we’ll sustain is the shift to rapid communities of learning across local, regional … We
can’t simply legislate our way into putting more colleagues at the bedside as the determinant that
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psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
August 21, 2024 - may actually precede hypotension) that does not respond immediately to a fluid bolus needs careful bedside … Often, a bedside sonogram will identify a significant intra-abdominal fluid collection. … 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 … May 23, 2018
The radiology impact of healthcare errors during shift work.
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psnet.ahrq.gov/node/49694/psn-pdf
October 01, 2013 - there are other examples of wrong patient errors that led to death.(8)
Although there are no published reports … recommended strategies for reducing the risk of wrong patient errors based on expert consensus and
analyzing reports … A patient verification
process is needed everywhere, not just at the bedside. … MEDMARX 5th Anniversary Data Report: A Chartbook of 2003 Findings and Trends 1999–2003. … Readers should not interpret any statement in this report as an official position of AHRQ or
of the