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psnet.ahrq.gov/node/33660/psn-pdf
December 01, 2007 - The state of Maine has mandated that all hospitals
publicly report care transition measure scores, and … psnet.ahrq.gov/issue/care-transitions-intervention-results-randomized-controlled-trial
cabinet, by the bedside … The first key attribute is easier to say and much
harder to do, and that is to make that shift from … In Chapter 5 of the June 2007 report, they outlined two fundamental steps. … The first step
would be to begin to mandate that hospitals publicly report their risk-adjusted 30-day
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psnet.ahrq.gov/web-mm/are-you-mrs-issue-identification-over-telephone
January 01, 2016 - 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 U.S
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psnet.ahrq.gov/web-mm/one-dose-two-errors
September 29, 2017 - The report was received by the nurse and relayed to the covering resident. … revealed that the information about the positive yeast culture had been correctly called in to the bedside … pharmacists.( 10 ) Team members are aware of key aspects of each patient's medical problems and laboratory reports … quality by rapidly notifying radiologist of report errors. … Benign
April 1, 2009
WebM&M Cases
Dangerous Shift
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psnet.ahrq.gov/perspective/emergence-application-based-healthcare
August 05, 2022 - https://www.iqvia.com/insights/the-iqvia-institute/reports/digital-health-trends-2021 . … I was at the bedside with my father experiencing what patients go through every day. … I wonder if we could shift the conversation to thinking about safety implications. … issues including heart attacks, hypertension, being a cigarette smoker, and working late nights as a 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/conversation-francoise-marvel-md
August 05, 2022 - I was at the bedside with my father experiencing what patients go through every day. … I wonder if we could shift the conversation to thinking about safety implications. … issues including heart attacks, hypertension, being a cigarette smoker, and working late nights as a shift … https://www.iqvia.com/insights/the-iqvia-institute/reports/digital-health-trends-2021 . … 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/resuscitation-errors-shocking-problem
October 19, 2022 - Drug Administration (FDA) reviewed data from the FDA's Medical Device Reporting System (including 1327 reports … With regard to equipment problems such as those described by the case in question, a daily (or per shift … Cardiopulmonary resuscitation of adults in the hospital: a report of 14,720 cardiac arrests from the … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S … June 7, 2017
A dynamic risk management approach for reducing harm from invasive bedside
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psnet.ahrq.gov/node/49621/psn-pdf
March 01, 2011 - communicated the minimal intake of fluids and poor urine output to the day nurse at the
7:00 AM change of shift … Tools to assist in managing children, such as computerized bedside management systems (that can
both … 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/49663/psn-pdf
September 01, 2012 - 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 … authors has any affiliation or financial
involvement that conflicts with the material presented in this report
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psnet.ahrq.gov/issue/misgivings
March 17, 2021 - July 21, 2021
Barriers to and facilitators of bedside nursing handover: a systematic … November 4, 2015
The effect of staff nurses' shift length and fatigue on patient safety
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psnet.ahrq.gov/node/860050/psn-pdf
January 04, 2024 - small (5mm)
subdural hemorrhage overlying the left frontal convexity without mass effect or midline shift … The bedside parent may
not give an accurate history or may not even know the accurate history. … 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 … View AHRQ Disclaimers
https://psnet.ahrq.gov//mailto:jnmagana@ucdavis.edu
https://www.acf.hhs.gov/cb/report
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psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
November 15, 2023 - Develop bedside point-of-care bar code scanning, and support or champion other system improvements that … Shift the paradigm from reactive risk management to proactive management. … Promptly report results to parents. … 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/33662/psn-pdf
January 01, 2008 - It also made the people at the bedside feel really good that they had been
able to change and improve
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psnet.ahrq.gov/periodic-issue/periodic-issue-373
December 14, 2022 - issue highlights what's new this week in patient
safety literature, news, conferences, reports … The action plan proposed by this project includes ensuring a just culture so staff feel empowered to report … Non-invasive bedside sensors monitored patients’ vital signs and automatically sent alerts to the RRT … Faculty and interns report the ART framework was highly structured, specific, formative, and facilitated … The action plan proposed by this project includes ensuring a just culture so staff feel empowered to report
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psnet.ahrq.gov/node/49857/psn-pdf
March 01, 2019 - insulin-related hypoglycemia and errors occur annually, with 30%
resulting in hospital admission.(2) One report … the most common error, and errors were identified during
pharmacists' consultative activities at the bedside … Readers should not interpret any statement in this report as an official position of AHRQ or
https:/ … authors has any affiliation or financial
involvement that conflicts with the material presented in this report
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psnet.ahrq.gov/node/866205/psn-pdf
July 10, 2024 - the postanesthesia care unit
(PACU), where the nurse called the attending physician three times to report … Damage control surgery is the shift from
completing a procedure to gaining control of bleeding and contamination … The nurses at the bedside were apparently unable to elevate their
concerns, as TeamSTEPPS instructs, … 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/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
January 01, 2024 - bleeding in the postanesthesia care unit (PACU), where the nurse called the attending physician 3 times to report … Damage control surgery is the shift from completing a procedure to gaining control of bleeding and contamination … The nurses at the bedside were apparently unable to elevate their concerns, as TeamSTEPPS instructs,
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psnet.ahrq.gov/perspective/conversation-suchi-saria-phd
March 27, 2024 - Previously, they wouldn't be standing by the bedside watching the patient continuously. … 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/842919/psn-pdf
February 01, 2023 - The ED can be a hectic
environment with many provider hand-offs and shift changes between bedside nurses … National Diabetes Statistics Report website. Centers for Disease Control and Prevention. … Readers should not interpret any statement in this report as an official position of AHRQ or
https:/ … /bmjopen-2017-016587
https://doi.org/10.1111/dme.14788
https://www.cdc.gov/diabetes/data/statistics-report … authors has any affiliation or financial
involvement that conflicts with the material presented in this report
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psnet.ahrq.gov/perspective/conversation-kathleen-sanford-and-sue-schuelke-about-virtual-nursing
August 30, 2023 - If you’re on the night shift, you can call up your nurse preceptor and talk things through. … If somebody was short on a night shift, we would ask, “Where’s an extra nurse? … Many times in healthcare, we look at what the issue is right now, just like our example about a night shift … equipped with a wall-mounted camera, speakers, a large-screen video monitor, and tablet computers for 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/perspective/virtual-nursing-improving-patient-care-and-meeting-workforce-challenges
August 30, 2023 - equipped with a wall-mounted camera, speakers, a large-screen video monitor, and tablet computers for bedside … If you’re on the night shift, you can call up your nurse preceptor and talk things through. … If somebody was short on a night shift, we would ask, “Where’s an extra nurse? … Many times in healthcare, we look at what the issue is right now, just like our example about a night shift … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S