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Total Results: 749 records

Showing results for "bedside shift report".

601. Right Regimen, Wrong Cancer: Patient Catches Medical Error | PSNet
     psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
     August 01, 2006 - In the morning his bedside nurse for the day came in and stated that she would be giving him his fourth … A national trend, in place for more than a decade, has resulted in a shift in the setting in which chemotherapy … The shift of oncology inpatient care to outpatient care: the challenge of retaining expert oncology nurses … 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

602. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74713/psn-pdf
     January 26, 2022 - When the morning shift started, the new nursing assistant called the team to bedside as the patient … repeat opioid dosing in a narrow period of time may not relieve the patient’s pain and can dramatically 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

603. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/865655/psn-pdf
     April 24, 2024 - The patient was discharged that afternoon despite continuing to report extreme pain. … Diagnosis Historically, CS has been diagnosed by bedside assessment using various clinical signs and … Did resident duty hours or shift work play a role in the delayed diagnosis, and if so, how? … In addition, we recommend concurrent bedside patient examination of patients who are being evaluated … Readers should not interpret any statement in this report as an official position of AHRQ or of the

604. The LifePoint National Quality Program Provides Structured Framework for Reducing Inpatient Harm | PSNet
     psnet.ahrq.gov/innovation/lifepoint-national-quality-program-provides-structured-framework-reducing-inpatient-harm
     February 26, 2025 - can easily be replicated across hospitals (e.g., TeamSTEPPS, the use of interdisciplinary care teams, bedside … shift reports, prioritizing patient engagement) and providing guidance on how to implement and master

605. Video to Improve Patient Safety: Clinical and Educational Uses | PSNet
     psnet.ahrq.gov/perspective/video-improve-patient-safety-clinical-and-educational-uses
     March 01, 2004 - EndNote 7 XML Endnote tagged PubMedId RIS Download Citation Perspective Reports … equipment, and team interactions.( 5 ) In contrast to administrative records, patient charts, and incident reports … addition to illustrating technical procedures, video is used for dissemination of best practices, such as bedside … shift change reporting, and for instructions of how to operate devices (such as infusion pumps) safely … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S

606. Harnessing the Potential of Health Care Collaboratives: Lessons from the Keystone ICU Project (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Goeschel_24.pdf
     January 01, 2008 - we encouraged teams to acknowledge and support both formal (e.g., CEO) and informal leaders (e.g., bedside … • Analyzing data and generating reports. … Problem-solving responsibility must shift from authoritative experts to those required to change their … This shift in authority has the potential to create conflict between the nurse and physician or other … Similar to clinical research, we committed to describe, conduct, and report the analyses appropriately

607. Despite Clues, Failed to Rescue | PSNet
     psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
     August 02, 2015 - Bedside evaluation revealed she was hypotensive (blood pressure 75/45 mm Hg), tachycardic (heart rate … The intensive care unit (ICU) team consulted at the bedside and made plans to transfer her to the ICU … Early warning scores use risk prediction, typically generated each shift, based on vital signs and information … Natl Health Stat Report. 2010;29:1-20, 24. [go to PubMed] 3. … December 5, 2018 Using incident reports to assess communication failures and patient

608. The National Action Alliance to Advance Patient Safety Summer Webinar Series: CDC Presentation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/addressing-workforce-safety-062723.pdf
     July 25, 2023 - changing or different professional roles or values and power differentials among staff, and staff and shift … Key findings were bedside nursing program participants felt more confident and capable of managing aggressive … Formal reports of patient aggression episodes did not increase during the study. … Continuous improvement should be the goal Cultural shift and empowering colleagues Communication … the Healthcare Industry “The reality is if you ask emergency nurses, they will tell you every single shift

609. Implementing Your Surgical Site Infection Prevention Bundle: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/implementation/ssi-bundle-slides.html
     October 01, 2020 - Slide 6: AHRQ Safety Program for Surgery—Implementation Translating Evidence Into Bedside Practice … The next columns provide space to record the Investigator and the Shift Second section of the BIM tool … Essential to report progress to your team: Track your surgical site infection rates and detect trends … Impact of preoperative briefings on operating room delays: a preliminary report.

610. Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture. | PSNet
     psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-compartment-syndrome-after-lower-leg-fracture
     November 25, 2020 - The patient was discharged that afternoon despite continuing to report extreme pain. … Diagnosis Historically, CS has been diagnosed by bedside assessment using various clinical signs and … Did resident duty hours or shift work play a role in the delayed diagnosis, and if so, how? … In addition, we recommend concurrent bedside patient examination of patients who are being evaluated … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S

611. Navigating-Hierarchy-Transcript (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/navigating-hierarchy-transcript.doc
     December 10, 2013 - I keep getting reports from my committee members who are in house today about not being able to get back … It’s the 1910 Flexner Report. … I know for me that that time was back in the early ‘90s when I was part of a, mostly an evening shift … It was during resident rounds at the bedside. … we report that we caught a mistake just in time.

612. Navigating Hierarchy in the Clinical Setting: Working and Communicating with Others (December 10, 2013) | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/navigating-hierarchy-transcript.html
     December 01, 2017 - I keep getting reports from my committee members who are in house today about not being able to get back … It's the 1910 Flexner Report. … I know for me that that time was back in the early '90s when I was part of a, mostly an evening shift … It was during resident rounds at the bedside. … we report that we caught a mistake just in time.

613. Too Many Cooks in the Kitchen | PSNet
     psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
     March 07, 2018 - deterioration before the outcome became inevitable, a hospital-wide  Early Warning System  based on networked bedside … 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

614. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49694/psn-pdf
     October 01, 2013 - there are other examples of wrong patient errors that led to death.(8) Although there are no published reports … recommended strategies for reducing the risk of wrong patient errors based on expert consensus and analyzing reports … A patient verification process is needed everywhere, not just at the bedside. … MEDMARX 5th Anniversary Data Report: A Chartbook of 2003 Findings and Trends 1999–2003. … Readers should not interpret any statement in this report as an official position of AHRQ or of the

615. Mismanagement of Delirium | PSNet
     psnet.ahrq.gov/web-mm/mismanagement-delirium
     February 13, 2014 - loved one's care and requested alternate ward placement that allowed a 24-hour family caregiver at the bedside … The patient continued to act out dreams, but having a family caregiver at the bedside prevented escalation … 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

616. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy | PSNet
     psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
     September 30, 2020 - Abnormal findings should trigger more thorough bedside evaluation, including history-taking and physical … An alert with the institution's protocol for abnormal obstetric vital signs could help prompt urgent bedside … Obstet Gynecol . 2015;126:155–62. [ Free full text ] R 3 Report – Requirement, Rationale, Reference … The Joint Commission. [ Available at ] R 3 Report: Provision of Care, Treatment, and Services standards … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S

617. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/838972/psn-pdf
     October 27, 2022 - During the night shift, the hospital unit was short- staffed, and her external catheter system fell … By the time the nurse came to the bedside to change the patient’s urine-soaked bed pads and sheets, the … 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

618. One Dose, Two Errors | PSNet
     psnet.ahrq.gov/web-mm/one-dose-two-errors
     September 29, 2017 - The report was received by the nurse and relayed to the covering resident. … revealed that the information about the positive yeast culture had been correctly called in to the bedside … pharmacists.( 10 ) Team members are aware of key aspects of each patient's medical problems and laboratory reports … quality by rapidly notifying radiologist of report errors. … Benign April 1, 2009 WebM&M Cases Dangerous Shift

619. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33786/psn-pdf
     May 01, 2015 - psnet.ahrq.gov/perspective/video-improve-patient-safety-clinical-and-educational-uses Perspective Reports … equipment, and team interactions.(5) In contrast to administrative records, patient charts, and incident reports … addition to illustrating technical procedures, video is used for dissemination of best practices, such as bedside … shift change reporting, and for instructions of how to operate devices (such as infusion pumps) safely

620. An Untimely End Despite End-of-Life Care Planning | PSNet
     psnet.ahrq.gov/web-mm/untimely-end-despite-end-life-care-planning
     February 01, 2012 - However, this occurred at the end of shift, and the resident did not verbally communicate the order change … and suggests that transitions to comfort care in the ICU should not occur unless the family is at the bedside … 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