-
psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
September 23, 2024 - This shift in mindset can promote patient safety. … of the Innovation
The Institute for Healthcare Policy and Innovation at the University of Michigan reports … injury, deterioration following issues with postoperative fluid management , and decompensation during bedside
-
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).
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/tool_safe-e-fetal-monitoring.docx
May 01, 2017 - Clinician pocket cards and bedside reference aids that describe the 2008 NICHD nomenclature and three-tier … This may include bedside review by nursing team of patient’s recent EFM strip, interpretation, and any … The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal … The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal … The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal
-
psnet.ahrq.gov/curated-library/patient-team-member-clinical-care
March 15, 2025 - This report... … Physician reviewers evaluated parents' reports and designated incidents as errors or quality issues or … The study team's clinician review panel assessed patient concerns and shared reports deemed to be safety … clinicians and patients, the guide emphasizes four strategies—working with patients as advisors, improving bedside … communication, integrating patients and families into shift changes, and using patient input to improve
-
www.ahrq.gov/teamstepps-program/curriculum/team/tools/index.html
July 01, 2023 - effective strategies for involving patients and family caregivers include:
Engaging the patient in bedside … Conducting handoffs at the patient’s bedside. … Selected Resources
The AHRQ-funded Guide to Patient and Family Engagement: Environmental Scan Report … should strive to create a learning culture of trust and transparency that creates a safe environment to report
-
psnet.ahrq.gov/node/837913/psn-pdf
August 31, 2022 - Her
parents demanded transfer to a specialty hospital, but there was a shift change and the new emergency … Second, the shift change introduced a new treating physician who did not recognize
the necessity of … A telehealth connection to bring the pediatric intensivist and transport team to the child’s
bedside … The
use of I-PASS for patient handoffs during inpatient pediatric shift changes was found to decrease … Brief report: the impact of maternal posttraumatic
stress disorder symptoms and child gender on risk
-
psnet.ahrq.gov/perspective/conversation-withdonald-m-berwick-md-mpp
November 01, 2005 - Speed and agility are values, which are to keep up with the industry, keep up with the needs, to shift … when we have to shift, and to change when we've done something wrong. … Others report that standing by a deteriorating patient with no resources to help—in the absence of an … If a response is defined as a thorough bedside evaluation by a team member who possesses some critical … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S
-
psnet.ahrq.gov/node/33803/psn-pdf
January 01, 2015 - The 2014 report showed progress in a variety of areas—most notably access
to care. … As noted in the recent IOM report, we don't yet have good measures of diagnostic accuracy. … and Safety focuses on four
https://psnet.ahrq.gov/issue/national-healthcare-quality-and-disparities-reports … Third, enhancing continuity of care by keeping the patient and family
informed through nurse bedside … change-of-shift reports, assuring that during shift changes it is not simply
one nurse talking with
-
psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
May 19, 2021 - organizational use of glycemic control protocols through their role in administering these protocols at the bedside … This raises the question of what information was covered in the change of shift handoff regarding glucose … Fact Sheet—Report on the Operational Use of Flight Path Management Systems. … Organization Inadequate handoff communication between physicians and between nurses upon change of shift … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S
-
psnet.ahrq.gov/web-mm/ebola-are-we-ready
July 01, 2012 - moment three different elevators arrived on the ground floor, more than 30 staff members (at their shift … the closest elevator, but this was a bay designated for staff—who were just leaving at the end of a shift … Clinical outcomes after bedside and interventional radiology paracentesis procedures. … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S … , 2012
Process changes to increase compliance with the Universal Protocol for bedside
-
psnet.ahrq.gov/node/867206/psn-pdf
December 18, 2024 - Imprecision in patient reports of dizziness
symptom quality: a cross-sectional study conducted in an … Acute dizziness: A personal journey through a paradigm shift. Acad Emerg Med.
2023;30(5):598-602. … Major neurological deficit following neck hyperextension during
dental treatment: report of 2 cases … Beauty parlor stroke syndrome: report of five cases. JAMA. 1993;269(16):2085-2086. … Readers should not interpret any statement in this report as an official position of AHRQ or
of the
-
psnet.ahrq.gov/node/60865/psn-pdf
August 31, 2020 - KH: I assume that it takes time to see the culture shift, over years. … Or is it just a paradigm
shift of how your thinking of the care you are providing? … EL: It’s a paradigm shift. … The paradigm shift about the value of who that person is in the bed is key. … But care at the bedside,
and of course I am a little bit biased, is very good.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Montgomery_42.pdf
March 05, 2008 - More staff know how to report events and near misses and can describe
how the information is used. … Subsequently, executives provided
quarterly reports detailing actions taken to address the events. … An additional
objective was to demonstrate that safety walk rounds led by bedside providers can achieve … a near miss or
actual event or what was done with the information if a report was made. … • Do you know how the information from occurrence reports is used in this hospital?
-
psnet.ahrq.gov/perspective/conversation-sharon-k-inouye-md-mph
December 01, 2012 - No one even understood what it was, how you recognized it at the bedside, what patients were vulnerable … 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 … Large-scale implementation of sedation and delirium monitoring in the intensive care unit: a report from … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S
-
psnet.ahrq.gov/perspective/conversation-neel-shah-md-mpp
October 30, 2019 - One of our leading theories has to do with presence at the bedside. … Changing the "routine care" paradigm requires a cultural shift and a reorientation of thinking focused … POKE scores are discussed by the bedside nurse. … 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
-
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
-
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
-
psnet.ahrq.gov/web-mm/wrong-route-nutrients
September 04, 2010 - The LPN on the night shift mistakenly hooked up the total nutrient fluid prepared for the central line … Recognizing the mistake, the LPN returned to the patient's bedside to correct the error, disconnected … The Commentary We interpret reports of medical error through the prism of our own underlying assumptions … Final Report to Agency for Healthcare Research and Quality; 2007. 6. … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S
-
psnet.ahrq.gov/node/49808/psn-pdf
October 01, 2017 - The bedside nurse received education about treprostinil, with special instructions
not to flush the … However, research to date has primarily concentrated on intradisciplinary sign-offs among physicians, shift … report among nurses, and interdisciplinary communication among primary clinical team members. … An analysis of the reports submitted to the Australian Incident Monitoring
Study in Intensive Care. … Readers should not interpret any statement in this report as an official position of AHRQ or
of the
-
psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
November 01, 2005 - the intervention is that an RRT program brings individuals with critical care skills promptly to the bedside … Others report that standing by a deteriorating patient with no resources to help—in the absence of an … If a response is defined as a thorough bedside evaluation by a team member who possesses some critical … Speed and agility are values, which are to keep up with the industry, keep up with the needs, to shift … when we have to shift, and to change when we've done something wrong.