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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cauti-event-reporting-revised.docx
April 01, 2022 - CLABSI Event Reporting Tool
CAUTI Event Report Tool: Data for Event Analysis
This event report tool … Lastly, do not wait too far out to complete the event report tool as it may be difficult to fill in the … (e.g., tamper-evident seal intact, no documentation or staff reports of breach in system) ☐ YES ☐ NO … Is the presence of a urinary catheter and date of insertion included on all transfer/shift report checklists … Applying mindful evidence-based practice at the bedside using catheter-associated urinary tract infection
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/170-cusp-science-safety-notes.docx
October 01, 2024 - Preventable Harm
SAY:
Healthcare has focused on safety since the Institute of Medicine released a report … Although significant improvements occurred following that report, there’s still a tremendous need for … According to a World Health Organization report, 1 in 10 patients are harmed when they stay in a hospital … Due to psychological safety, there is no risk when people report their errors and near-misses.
3. … And, when you need to know what is going on at the bedside, ask.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod3sess3.html
October 01, 2014 - But even if you think a mistake may have happened, you must report the change. … Residents are most protected from harm or injury when providers openly report anything that might affect … events) or look as if they are about to (near-misses), we may feel embarrassed and worry that if we report … 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.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/engaging-nurse-physician-patient.pptx
May 28, 2015 - 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 … When = Rounding, every shift
Why = Provide the stats, harm, cost
8
Providing the Tools to Succeed … Unit
Saint Joseph Mercy Hospital
Ann Arbor, Michigan
53
Finding the Defects
54
Staff feedback
Shift … Event reporting
Root Cause Analysis, hospital reporting system
Quality and safety measures
Monthly data reports
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www.ahrq.gov/hai/cauti-tools/archived-webinars/urine-culture-practices-icu-slides.html
December 01, 2017 - Determine how bedside staff are feeling related to communication and recognizing defects:
Diagnose … and Communication about Error:
We are given feedback about changes put into place based on event reports … Evidence Based Local Solutions: Teamwork “If-Then”
If staffing levels inadequate/info lost at shift … change:
Then Morning/Shift Briefings
If interdisciplinary patient management issues:
Then
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www.ahrq.gov/hai/tools/surgery/modules/on-boarding/science-of-safety-fac-notes.html
December 01, 2017 - a surgical site infection, wrong-site surgery, missing equipment, nursing time spent away from the bedside … Residents report receiving inaccurate information during rounds: An electronic progress note system was … forms are readily available so staff members can complete the PSSA whenever they have something to report … important to consider and plan how you will train staff and others who work off hours such as the overnight shift
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/reports-and-case-studies/WR_751_AHRQ_Quigley_08_26_10.pdf
April 01, 2010 - Those findings were confirmed by patient complaint data, monthly
reports collected from patients through … News
and World Report” annual report on hospitals also indicated a need for improvement. … News and World Report” annual hospital
rankings.
When? … The efforts included: (1) developing bedside descriptors to explain to patients the roles of
attending … The assignment
to each position/shift was determined by seniority.
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses.pdf
August 01, 2022 - example, nursing work is structured so
that nurses have frequent patient interactions throughout a shift … Another artifact is the paper-based task sheet nurses frequently develop at the beginning of a shift. … Cognition
+
+
4
Nurses’ Role in Diagnosis, Through the Lens of
Distributed Cognition
The landmark report … Finally, dyad combinations are not fixed and may change frequently during an ED shift, with one physician … Impact of altered medica-
tion administration time on interdisciplinary bedside rounds on academic medical
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_facnotes.docx
December 01, 2017 - a surgical site infection, wrong-site surgery, missing equipment, nursing time spent away from the bedside … Residents report receiving inaccurate information during rounds: An electronic progress note system was … forms are readily available so staff members can complete the PSSA whenever they have something to report … important to consider and plan how you will train staff and others who work off hours such as the overnight shift
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/intro-early-mobility-slides.pptx
January 01, 2017 - Critical Illness3
Data from longitudinal prospective study, pre-baseline information collected by self-report … to sitting
11 percent involved sitting over the edge of the bed
11 percent involved standing at the bedside
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/hospital/compare/WR_751_AHRQ_Quigley_08_26_10.pdf
April 01, 2010 - Those findings were confirmed by patient complaint data, monthly
reports collected from patients through … News
and World Report” annual report on hospitals also indicated a need for improvement. … News and World Report” annual hospital
rankings.
When? … The efforts included: (1) developing bedside descriptors to explain to patients the roles of
attending … The assignment
to each position/shift was determined by seniority.
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/guide/apf.html
October 01, 2017 - Description: The Implementation Team shared details about their initiative via a board report, a presentation … information with your board and other administrative leaders through multiple avenues (e.g., meetings, reports … nurse manager validated orders, and the quality representative checked charts and conducted random bedside … 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
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.pdf
May 01, 2017 - • Conducting change-of-shift report at
the bedside so patients and families
can participate. … • Report. … Providers report the incident to
the unit manager and the risk-
management department, according to
the
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www.ahrq.gov/sites/default/files/publications2/files/distributed-cognition-er-nurses_0.pdf
August 01, 2022 - example, nursing work is structured so
that nurses have frequent patient interactions throughout a shift … Another artifact is the paper-based task sheet nurses frequently develop at the beginning of a shift. … Cognition
+
+
4
Nurses’ Role in Diagnosis, Through the Lens of
Distributed Cognition
The landmark report … Finally, dyad combinations are not fixed and may change frequently during an ED shift, with one physician … Impact of altered medica-
tion administration time on interdisciplinary bedside rounds on academic medical
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu3.html
October 01, 2014 - prevention, it is necessary to recognize at the outset that implementing these best practices at the bedside … In some settings, though, it may be done as frequently as every shift. … Positive reinforcement will help when nursing assistants do find and report new abnormalities. … Having staff who do not feel empowered to report abnormal skin findings: Communication among nursing … Including results as part of patient report or handover.
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www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/pu3.html
October 01, 2014 - prevention, it is necessary to recognize at the outset that implementing these best practices at the bedside … In some settings, though, it may be done as frequently as every shift. … Positive reinforcement will help when nursing assistants do find and report new abnormalities. … Having staff who do not feel empowered to report abnormal skin findings: Communication among nursing … Including results as part of patient report or handover.
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www.ahrq.gov/research/findings/studies/index.html?page=316
January 01, 2024 - The service consisted of a bedside consult and phone follow-up 3, 14, and 30 days after hospital discharge … Jump RL , Nace DA Improving management of urinary tract infections in older adults: a paradigm shift … Improving management of urinary tract infections in older adults: a paradigm shift or therapeutic nihilism
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www.ahrq.gov/research/findings/studies/index.html?page=11
January 01, 2024 - A total of 3,861 medication related patient safety event reports that were previously annotated using … A text mining approach to categorize patient safety event reports by medication error type. … complete an abbreviated Mindful Attention Awareness Tool and a survey on diagnostic confidence upon shift … The objective of this Web-based survey was to describe variation in bedside and laboratory-level blood … have a procedural competency, did not document sample volume, did not receive a culture contamination report
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Browne_5.pdf
January 20, 2008 - As each RCA
is completed, reports are shared with senior leaders and discussed each month at the Patient … recommended action item
was “not feasible” might have related to the transfer of patients on night shift … not be feasible at this
time to create a rule or standard that no patients be transferred on night shift … monitor alarms, with the stipulation that the
nurse needs to be physically present at the patient’s bedside … Measures are tracked monthly, and
regular progress reports are provided in a number of forums.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/cauti-sustainability-transcript.docx
January 01, 2014 - On the genitourinary shift assessment, the same thing is there and this is required every shift. … We have to report out to infection prevention council.
This is our analysis tools that we have. … From the bedside of the boardroom, it matters. … This is quick screenshot of our shift huddle. This is how we start each shift. … CUSP improvement tools are designed for the bedside caregivers easy for the staff to use.