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www.ahrq.gov/sites/default/files/2024-04/dykes-report.pdf
January 01, 2024 - Final Progress Report: Generalizability and Spread of an Evidenced-based Fall Prevention Toolkit: Fall … TIPS audit tool is composed of three questions: 1) Is the patient’s Fall TIPS
poster hanging at the bedside … Based
on published literature and ranking of injurious fall incident reports (n=85) from Brigham and … therapists, pharmacists, and para-professionals) varied by position, education, years of experience, shift … implemented was as follows: 75% for question 1 (is the Fall TIPS poster updated and hanging at the
bedside
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www.ahrq.gov/hai/cauti-tools/archived-webinars/engaging-nurse-physician-patient-slides.html
August 01, 2018 - Nurse OR gave report to Nurse ICU.
08/03/12 – Ms. C is stable. … C’s son was at the bedside during visiting hours, he stated he was angry and concerned that his mother … Root Cause Analysis, hospital reporting system
Quality and safety measures:
Monthly data reports … Slide 60
Image: Sample Post Fall Huddle report. … Slide 61
Image: Sample Post Fall Huddle report continued.
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/14289-Jack-draft-1.pdf
January 19, 2005 - Final Progress Report: Re-engineering the Hospital Discharge for Patient Safety--Safe Practices Implementation … qualitative research, probabilistic risk assessment, embodied
conversational agents
Page 2 of 19
Progress … Report
Table Of Contents
1. … We envision using such agents in
bedside hospital kiosks for patient education prior to discharge. … Perspectives of Patient
Safety: Five years After the IOM Report.
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www.ahrq.gov/sites/default/files/2024-01/jack-report.pdf
January 01, 2024 - Final Progress Report: Re-engineering the Hospital Discharge for Patient Safety--Safe Practices Implementation … qualitative research, probabilistic risk assessment, embodied
conversational agents
Page 2 of 19
Progress … Report
Table Of Contents
1. … We envision using such agents in
bedside hospital kiosks for patient education prior to discharge. … Perspectives of Patient
Safety: Five years After the IOM Report.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Clair.pdf
January 01, 2004 - Well-designed, quasi-experimental studies
Level IV Well-designed, non-experimental studies
Level V Case reports … was assessed with the use of an inventory of the
tracheostomy supplies available at each patient’s bedside … Aspiration with cuffed tube II E
Peruzzi, et al. (2001) Aspiration with dye III A
Henrich, et al. (1997) Bedside … A report of
the Committee on Quality of Health Care in America,
Institute of Medicine.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Maddox_38.pdf
March 26, 2008 - In the medication use process, the nurse at the bedside is most
vulnerable to errors.2 Compared with … was revised to require respiratory therapy to round on every PCA patient at
least once per 12-hour shift … This value is
the number of instances for which there are documented case reports. … However, no case reports were submitted. … ISMP medication
error report analysis. Hosp Pharm 2005; 40: 210-12.
32.
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www.ahrq.gov/research/findings/studies/index.html?page=2
January 01, 2024 - This report described uptake by primary care practices of cardiovascular disease (CVD) prevention materials … research staff using three prescreening tools (Criteria2Query, Informatics for Integrating Biology and the Bedside … Researchers conducted a prospective, patient-shift-level survey in two ICUs. … They surveyed each patients’ assigned physician, nurse, and respiratory therapist each shift about who … Patterns of interactions among ICU interprofessional teams: a prospective patient-shift-level survey
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www.ahrq.gov/teamstepps/rrs/instructor_slides/rrsinstructmod.html
October 01, 2014 - S
Safety Concerns —Critical lab values/reports, socio-economic factors, allergies, alerts (falls, isolation … Physician shift change (responsibility).
Evolving patient condition. … The keys for effective sensemaking can be found in the Battles, et al., Health Services Research report … The analyst responsible felt that most of the reports prepared in the past were not used by or of interest … The patient's stroke remained unidentified during evening shift.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Dingley_14.pdf
February 06, 2008 - professionals is one
of the leading causes of medical errors and patient harm.1, 2, 3 A review of reports … two most highly contributing factors,
according to the National Council of State Boards of Nursing reports … Team huddles during each shift. … and were led by a shift supervisor or department head. … with a
provider or to find information (e.g., the on-call physician’s phone number or a patient’s bedside
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www.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamilysum.html
July 01, 2018 - Purpose and Methods
This report presents the results of the environmental scan that serves as an evidence-based … Interventions and strategies used to engage patients and families as members of their health care team include bedside … rounds, bedside change of shift reports, patient- or family-activated rapid response teams, specific
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy1/Strat1_Implement_Hndbook_508_v2.pdf
January 28, 2011 - Shift
Report, and the IDEAL
Discharge Planning). … shift
report. … shift report, or discharge) … shift report) and
provide them with training on being an objective observer. … change-of-shift report).
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www.ahrq.gov/sites/default/files/publications/files/cuspsuccess.pdf
October 01, 2012 - Everyone knows what our organizational goals
are and gets the same reports. … committees
involving Target Zero, empowered staff to do the right thing, reviewed monthly data and
progress … reports, and attended celebrations for units achieving zero HAIs for at least a year. … The nurses in each of Saint Joe’s Critical Care Units report to a Nurse Manager, who in turn
report … bedside.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_lowvision.pdf
May 01, 2017 - This change also automated data
outputs and reports. … For example, the team
conducts each shift report in front of the patient and
concludes the report by … new behaviors by initiating huddles and debriefs during
and after a cesarean section and requesting reports … Under the protocol change, the bedside nurse notifies
the rapid response nurse and attending physician … The
bedside nurse now focuses on providing immediate care
to the patient and providing a report of
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_fullcolor.pdf
May 01, 2017 - This change also automated data
outputs and reports. … For example, the team
conducts each shift report in front of the patient and
concludes the report by … new behaviors by initiating huddles and debriefs during
and after a cesarean section and requesting reports … Under the protocol change, the bedside nurse notifies
the rapid response nurse and attending physician … The
bedside nurse now focuses on providing immediate care
to the patient and providing a report of
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_3-communication-speaker-notes.pdf
July 01, 2023 - transitions, and
recommending
changes to the
established care plan
Use SBAR to:
• Frame event reports … Finally, SBAR might be useful at the
Reporting stage to frame event reports, structure case scenarios … Sonentag, comes to check on patient Danielle Williams at her bedside nurse’s request. … As you read through this expanded section from our scenario, think about how the bedside
nurse, Allison … status, level of uncertainty,
recent changes, and response to treatment
• Safety: Critical lab values/reports
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_3_communication.pptx
July 01, 2023 - communications, care transitions, and recommending changes to the established care plan Use SBAR to:
Frame event reports … Finally, SBAR might be useful at the Reporting stage to frame event reports, structure case scenarios … Sonentag, comes to check on patient Danielle Williams at her bedside nurse’s request. … As you read through this expanded section from our scenario, think about how the bedside nurse, Allison … status, level of uncertainty, recent changes, and response to treatment
Safety: Critical lab values/reports
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/rrs/rrsinstructmod.ppt
January 01, 2008 - S Safety Concerns—Critical lab values/reports, socio-economic factors, allergies, alerts (falls, isolation … Physician shift change (responsibility).
Evolving patient condition. … The keys for effective sensemaking can be found in the Battles, et al., Health Services Research report … The analyst responsible felt that most of the reports prepared in the past were not used by or of interest … The patient’s stroke remained unidentified during evening shift.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/rrs/instructor_slides/rrsinstructmod.pdf
January 01, 2008 - S Safety Concerns—Critical lab values/reports, socio-economic
factors, allergies, alerts (falls, isolation … •
Physician shift change (responsibility).
•
Evolving patient condition. … The keys for effective sensemaking
can be found
in the Battles, et al., Health Services Research … report. … The patient’s stroke remained unidentified during
evening shift.
-
www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/implementation.html
January 01, 2013 - and nonclinical staff:
Reaching all nurses with fall prevention education, particularly night shift … Reports task completion to the nurse. … Reports any changes in the patient's condition to the nurse. … Ideally, there should be at least one champion per shift to provide guidance to other staff. … Clinical bedside rounds and patient case review are excellent ways to translate abstract knowledge into
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www.ahrq.gov/hai/cusp/toolkit/content-calls/empowerment.html
April 01, 2013 - CUSP improvement tools are designed for bedside caregivers, easy for busy staff to use, and it allows … Sometimes they’re at the beginning of the shift or mid-shift. … So we instead moved the meeting to a small report room which gets very crowded when we have 30 people … But I think that, again, if we focus on what matters to the nurse at the bedside, then they are very … We make it at the end of the shift, and that’s worked well.