-
www.ahrq.gov/sites/default/files/publications/files/ptflowguide.pdf
January 01, 2014 - Testing changes on a small scale (e.g., during a single shift) has several advantages. … The strategy that was least time-consuming to plan and implement was
bedside registration, which was … The open-bed policy gradually gained acceptance during the day shift. … It is the hope of ED
leadership that the night shift will soon follow in acceptance. … National Health Statistics Reports, No. 7.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kleinpeter.pdf
January 01, 2004 - follows: surgical suites, ambulatory clinics,
emergency departments, or hospital rooms (patient’s bedside … In addition, a summary of
incident reports is provided to infection control to track any trends in infectious … Most studies that report on medical error are primarily focused on hospitalized
patients. … Interim Report to the
Senate Committee on Appropriations. AHRQ
Publication No. 04-RG005. … A report of
the Committee on Quality of Health Care in America,
Institute of Medicine.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/system/systemredesignsafetynet/systemredesign.pdf
June 01, 2015 - In this report, we present only findings. … increased attention to
controlling health care costs is well documented in the literature, a multitude of reports … This positive shift in payer mix has led the system to develop and remodel aspects of its
infrastructure … mentioned grants from RWJF, such as the Aligning Quality
collaboratives and the Transforming Care at the Bedside … Examples include grant-funded
initiatives, such as RWJF’s Transforming Care at the Bedside program,
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Jones_29.pdf
February 23, 2008 - another.
57 40 87 11 58 34 84 13
2.c Important patient care information is often
lost during shift … occur in the exchange of
information across hospital departments. 52 29 84 12 54 29 74 12
4.c Shift … 63 51 79 9 49 28 70 11
1 to 2 event reports 16 4 34 8 24 11 33 7
3 to 5 event reports 13 5 31 8 … 15 8 31 6
6 to 10 event reports 5 0 6 2 7 0 14 4
11 to 20 event reports 2 0 6 2 4 0 17 5
21 event … quality improvement must engineer these interactions while
often continuing to provide care at the bedside
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Mitchell.pdf
March 31, 2004 - This represents a significant culture
shift, which can be prompted by tragic events (as in the case … Cardiac surgery care teams conducted daily
rounds at the patient’s bedside to share information and … A report to DHHS, HRSA. … A user’s manual for the IOM’s “Quality
Chasm” report. … Report G99-1. Glasgow, Scotland:
University of Glasgow; 1999.
-
www.ahrq.gov/sites/default/files/publications/files/ltcmodule3.pdf
June 01, 2012 - But even if you think a mistake may have
happened, you must report the change. … position, coming to rest on the ground or onto
the next lower surface (e.g., onto a bed, chair, or bedside … This may be because they do not read one another’s
notes or talk much at change of shift. … In most nursing centers, this involves
completing an incident report.
3. … Go beyond incident reports to help establish a revised care plan for falls
that corresponds to the individual
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/early-mobility-mvpguide.pdf
January 01, 2017 - It is possible to shift
the focus of nurse-driven mobilization to the time of acute illness. … The patient’s bedside
nurse revealed that the patient had not moved out of bed for 2 days. … Eliminating CLABSI, A National Patient Safety
Imperative: Final Report: Final Report on the
National … Curr Phys Med Rehabil Reports.
2013 Dec;1(4):307-14. PMID: 24436844.
31. … Curr Phys
Med Rehabil Reports. 2013
Dec;1(4):307-14. PMID: 24436844.
19.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Meliones_40.pdf
January 01, 2006 - ”
• Situation-background-assessment-recommendation (SBAR) communication for nursing
reports and telephone … The BSC
has now become the methodology for how each operating unit reports performance to the senior … Finally, control of the process can be difficult as priorities in the organization shift. … The champions must include physicians, managers, senior operational staff, and
bedside staff, who are
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/cauti-sustainability.pptx
December 01, 2015 - Organizational, Departmental, and Personal Goal
Urinary Catheter Insertion Assessment
54
GU Shift … boards to communicate data
68
Real Time Reporting
69
Staff can access data
on intranet page
Shift … patient care vs. what managers/directors think are priority areas
CUSP improvement tools are designed for bedside … evidence
We use it as the framework for post fall/skin huddles, morbidity and mortality conference, voice reports … Main Report
Healthcare-Associated Infections Report
Critical Care March CY 2015
Infection Summary
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/pu_training-impguide.docx
October 01, 2017 - will receive these reports. … work with the manager of the pilot unit(s) prior to this training to identify Unit Champions for each shift … Description: The Implementation Team shared details about their initiative via a board report, a presentation … Description: The SWAT has a representative from each unit and shift. … Nurse leaders, the Pressure Injury Prevention Program Lead, and bedside nurses are available to answer
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/introduction/intro-overview.pdf
March 01, 2022 - In fact, anaphylaxis has only been reported in case reports.97,98 Estimates for
these effects are expected … Report.
https://www.cdc.gov/hai/pdfs/progress-report/2018-Progress-Report-Executive-
Summary-H.pdf. … https://www.cdc.gov/hai/pdfs/progress-report/2018-Progress-Report-Executive-Summary-H.pdf
https://www.cdc.gov … /hai/pdfs/progress-report/2018-Progress-Report-Executive-Summary-H.pdf
Decolonization of Non-ICU Patients … As an alternative
to using impregnated cloths, we also provide a substitute protocol for bedside
basin
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/daily-care-processes-guide.pdf
January 01, 2017 - Translate Research Into Practice (TRIP), designed
to close the gap between evidence-based guidelines and bedside … • Share reports of the unit’s compliance with process and policy measures with staff on
the unit … a surgical site
infection, wrong-site surgery, missing equipment, nursing time spent away from the bedside … In order to learn from defects, we need
a shift in perspective, an attitude that errors and near misses … National
Healthcare Safety Network (NHSN) report: data
summary for 2006 through 2008, issued
December
-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/infusion-pumps-1.pdf
March 01, 2020 - Food and Drug Administration (FDA) received
approximately 56,000 reports of adverse events related to … Making Health Care Safer II report. … In the context
of infusion pumps, workflow may include having a staff hand-off procedure for shift changes … General methods for this report are described in the
Methods section of the full report. … General methods for this report are described in the Methods section of the full report.
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/043-vap-prevention-notes.docx
October 01, 2024 - Slide 23
Implementation
SAY:
This next section will shift the focus to implementation of interventions … requires purchasing a custom oral care kit that makes it easy for staff to have what they need at the bedside
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/g2_pdi_specifictoolstosupportchange.pdf
January 01, 2011 - http://www.vppartners.or
g/sites/default/files/report
s/full_rpt.pdf
Agency for
Healthcare
Research … quality
• Safe handoff of care between nurses
by involving the patient and family in
the change of shift … SafetySM initiative:
• Leading a Strategic Planning Effort
• Looking Collectively at Risk
• Assessing Bedside … readmission
http://www.wahospitalqu
ality.org/
Agency for
Healthcare
Research and
Quality
Report … Organization
Type of
Resource Name Description Source
Children’s Hospital
of Philadelphia
Report
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/g2_combo_specifictoolstosupportchange.pdf
January 01, 2011 - Venture
Philanthropy
Partners
Assessment
Tool
McKinsey
Capacity
Assessment Grid
(appendix of a
report … http://www.vppartners.or
g/sites/default/files/report
s/full_rpt.pdf
Agency for
Healthcare
Research … quality
• Safe handoff of care between nurses by
involving the patient and family in the change
of shift … Assessing Bedside Bar-Coding Readiness
http://www.ismp.org/tool
s/pathwaysection1.pdf
Health Services … quality-
resources/tools/hroadvice
/hroadvice.pdf
Canadian Health
Services
Research
Foundation
Report
-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/cre.pdf
September 26, 2019 - General methods for this report are described in the Methods section of the full report. … Rossi
Gonçalves
et al.,
201616
• Contact precautions
• Bedside alcohol gel
• Active screening … on CPE outbreaks
were included, with 53 reports from
Europe. … Although the risk of bias for selected
reports was high, the literature suggests
that CPE outbreaks … CP were implemented during
outbreak in addition to
bedside alcohol gel and
active screening.
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-measure-implementation.pdf
August 01, 2025 - Each description includes key findings
and/or results as reported in available final reports and/or … Doctors may use small talk to shift talk away from—
disattend—patients’ equivocal complaints or psychosocial … Patients may
use small talk to shift talk away from physician recommendations regarding
disfavored … Key Findings/Impact: In the final report, investigators noted that narrative
reports such as discharge … process of
developing and testing the smart digitalized checklist with customization to patient
and bedside
-
www.ahrq.gov/hai/tools/mvp/modules/technical/ltvv-intro-fac-guide.html
February 01, 2017 - Does this kind of tidal volume strategy paradigm shift apply not only to ARDS patients, but potentially … want a physician to be the custodian of the process, respiratory therapists are knowledgeable about bedside
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Shah_99.pdf
March 23, 2008 - Confidentiality of adverse event reports and their use as a feedback mechanism might be
Table 1. … Mechanisms that improve communication through
teamwork approaches for the reduction of bedside errors … Breaking point: Report calls for
congressional rescue of hospital emergency
departments. … The role of
clinical guidelines in medical negligence litigation: A
shift from the Bolam Standard? … The Institute of Medicine report on
medical errors – Could it do harm?