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psnet.ahrq.gov/web-mm/eptifibatide-epilogue
March 04, 2011 - The night shift nurse continued the infusion at this rate, as did the nurse on the following day shift … The day shift nurse was curious about the low dose and queried the intern, but the nurse was distracted … networks will help to maximize the value of electronic system double checks in the pharmacy and at the bedside … Safe Practices for Better Healthcare: 2009 Update: A Consensus Report. [Available at] 14. … June 16, 2019
ISMP medication error report analysis.
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psnet.ahrq.gov/node/33787/psn-pdf
January 01, 2018 - It was well before the publication of the IOM reports on safety and quality. … It was a shift from a sense of seeing events as only very rare lapses to seeing the whole system. … And they very much took their eye off the ball of what
was happening at the bedside. … attention to the little everyday events (like a unit that doesn't have enough staffing on the night shift … So we're very focused on keeping that connection between the boardroom and the bedside tight.
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digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015076-rosa-final-report-2007.pdf
January 01, 2007 - Transforming Healthcare Quality through Information Technology - Final Report
Grant Final Report
Grant … This report is in six sections. … additional pharmacy staff as well as resident physicians who can use the EMR technology at the
patient bedside … , thus reducing the distance information travels from its origin at the patient
bedside to a computer … discharge tool format was used to
establish a communication and hand-off tool that facilitates nursing shift
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psnet.ahrq.gov/web-mm/central-not-epidural
August 28, 2024 - Before leaving, she prepared a new bottle of lipids and left it at the bedside, as the current bottle … The problem was not discovered until the nurses on the next shift made rounds and checked the patient's … Numerous reports have documented unintentional failures to connect the correct tubing between intravenous … tubing connection is a routine, familiar, and common task in nursing, often performed many times on one 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/sites/default/files/import/webmm.ahrq.gov.398_slideshow.ppt
February 01, 2017 - an MRI of her brain (done for cancer staging) showed a right subdural hematoma with a 5 mm midline shift … The patient was alert and oriented when she arrived in the ED, but she did report falling and hitting … On that study, the radiologist noted that the subdural hematoma had enlarged and the midline shift had … Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a
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psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
December 04, 2016 - On the night shift, the bedside nurse went to see the patient at 3:00 AM to administer the next scheduled … He died peacefully with his family at the bedside. … adequate documentation convey the crucial information to everybody on the care team, including the night 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
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psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
September 01, 2012 - research you've done but also your evaluation of the Robert Wood Johnson "Transforming Care at the Bedside … RW : From your work in evaluating "Transforming Care at the Bedside," what did you learn about the bedside … onto a med–surg unit has 4 to 8 patients assigned, each of whom has a to-do list at the start of the shift … need to make sure that they're able to meet the nursing needs of those patients every day of their shift … This report will compile a wide range of data on the nursing workforce.
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www.ahrq.gov/sites/default/files/2024-01/barnsteiner-report.pdf
January 01, 2024 - Final Progress Report: : State of the Science on Safe Medication Administration
Title of Project: State … responding to unanticipated
changes in patient acuity and volume
• Return clinical nurse specialists to the bedside … environments
• Encourage comments from staff nurses
• Invite administrators and policymakers to observe bedside … As of
April 2005, over 2,500 viewers had accessed the report. … Nursing School Curricula
We have received reports that the work of the symposium and the report is being
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psnet.ahrq.gov/node/49724/psn-pdf
January 01, 2015 - The night resident was called to the patient's bedside multiple times overnight
by the charge nurse … The patient remained in sustained pain and the surgical team was called to the bedside multiple times … what needs to be done at different stages), address some of the issues that invariably arise with 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/node/49821/psn-pdf
February 01, 2018 - Studies of ADC-related errors report on diverse
patient populations with various control factors and … and barcode-assisted
medication administration (BCMA) can provide yet another check at the patient bedside … These actions remove some of the possible errors that
can occur in the process of bedside decision-making … Share and provide feedback on medication incident reports and experiences. … 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/perspective/conversation-chalapathy-venkatesan-and-kathy-helak-about-application-safety-ii
August 28, 2024 - We have conducted learning teams on early ambulation, bedside medications, oxygen safety, and care of … However, as we shift our culture, we have also shifted to referring to great catches and patient care … Anything we can do to enhance learning and bring the walls down, such as a shift in language, is what … If you ask registration, perioperative techs, or bedside nurses, you'll hear about things that folks … system and recognition of the importance of evaluating successes in addition to failures yielded a shift
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psnet.ahrq.gov/perspective/application-safety-ii-principles
August 28, 2024 - system and recognition of the importance of evaluating successes in addition to failures yielded a shift … We have conducted learning teams on early ambulation, bedside medications, oxygen safety, and care of … However, as we shift our culture, we have also shifted to referring to great catches and patient care … Anything we can do to enhance learning and bring the walls down, such as a shift in language, is what … If you ask registration, perioperative techs, or bedside nurses, you'll hear about things that folks
-
psnet.ahrq.gov/node/33742/psn-pdf
December 01, 2012 - No one even understood what it was, how you recognized it at the bedside, what
patients were vulnerable … In terms of recognizing it at the
bedside, you really do need to do some formal cognitive testing even … All these little things happen on the night shift because it's when things are otherwise
quieter. … have to do major room switches, if someone comes up VRE or MRSA positive, they
often do them on night shift … But right now the only way to reliably identify
the delirium is from someone going to the bedside.
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www.ahrq.gov/hai/tools/mvp/modules/technical/4es-early-mobility-facguide.html
February 01, 2017 - Initiate any therapy beyond feet dangling with the respiratory therapist at the patient’s bedside and … Educate your providers, either formally through lectures and demonstrations or informally at the bedside … Be sure to add the patient’s mobility level to the report sheet and nursing handoff. … This visual aid can be laminated and placed in the patient’s room on the white board, at the bedside, … initial mobility screen within 8 hours of ICU admission and reassess the patient mobility level every shift
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy1/Strat1_Implement_Hndbook_508_v2.docx
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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psnet.ahrq.gov/perspective/conversation-abraham-verghese-md
November 01, 2012 - As we come to the bedside more, we will in a sense come together from both ends. … Examination as a Patient Safety Practice
November 1, 2012
Perspective
Near the end of his shift … laboratory tests, electrocardiograms, cross-sectional body images, endoscopic findings, microscopic 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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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressureulcertoolkit/putoolssect7.docx
February 16, 2011 - Are performance reports used regularly for decisionmaking?
4. … A turning schedule should be written and placed at the bedside.
13. … A turning schedule should be written and placed at the bedside.
True
13. … What should you report to your patient’s RN every shift?
A. Skin tears
B. … What should you report to your patient’s RN every shift?
A. Skin tears
B.
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www.ahrq.gov/hai/cauti-tools/archived-webinars/navigating-hierarchy-slides.html
December 01, 2017 - years ago, a series of studies about the education of health professionals, led by the 1910 Flexner report … Bedside Calculations as “Shame and Blame”
“My name is Greg.”
Slide 11
Plasticity vs.
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psnet.ahrq.gov/perspective/preparing-health-reform-federal-government-and-nursing-workforce
September 01, 2012 - This report will compile a wide range of data on the nursing workforce. … research you've done but also your evaluation of the Robert Wood Johnson "Transforming Care at the Bedside … RW : From your work in evaluating "Transforming Care at the Bedside," what did you learn about the bedside … onto a med–surg unit has 4 to 8 patients assigned, each of whom has a to-do list at the start of the shift … need to make sure that they're able to meet the nursing needs of those patients every day of their shift
-
digital.ahrq.gov/sites/default/files/docs/reducing-provider-burden-slides-012518.pdf
January 25, 2018 - GWV-Hospitalist
(Hundt et al., 2017)
GWV-CCM
Activities in blue = performed during
multidisciplinary bedside … Cross-Case Analysis
Cross-case analysis table
[focus on interruption & re-initiation] 11 case reports … • Reports focused on EHR-related
medical malpractice identified
over 80% of the reported events … Usability 33%
Actions
6%
Policies & procedures 6%
Harm
The Joint Commission Report … The Joint Commission Report. on EHR-related errors (n=120).