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psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
July 08, 2022 - When the morning shift started, the new nursing assistant called the team to bedside as the patient was … 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 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-witheric-coleman-md-mph
December 01, 2007 - The state of Maine has mandated that all hospitals publicly report care transition measure scores, and … There are medications in the medicine cabinet, by the bedside, on the lazy Susan. … The first key attribute is easier to say and much harder to do, and that is to make that shift from being … In Chapter 5 of the June 2007 report, they outlined two fundamental steps. … The first step would be to begin to mandate that hospitals publicly report their risk-adjusted 30-day
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psnet.ahrq.gov/perspective/care-transitions
December 01, 2007 - The state of Maine has mandated that all hospitals publicly report care transition measure scores, and … There are medications in the medicine cabinet, by the bedside, on the lazy Susan. … The first key attribute is easier to say and much harder to do, and that is to make that shift from being … In Chapter 5 of the June 2007 report, they outlined two fundamental steps. … The first step would be to begin to mandate that hospitals publicly report their risk-adjusted 30-day
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Keyes.pdf
January 01, 2004 - Based on the IOM and QuIC reports, reviews of the literature, and AHRQ’s
use of the research agenda … • Use of bedside technology to improve medication safety in nursing
homes and residential care/assisted … However,
the release of that report catapulted patient safety to the forefront of attention. … A report of
the Committee on Quality of Health Care in America,
Institute of Medicine. … Shift work and its
impact upon nurse performance: current knowledge
and research issues.
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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
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/sustainability/premortem-scorecard-facguide.docx
January 01, 2017 - For example, test a new tool with one provider on a shift or two. … Ideally, data are available close to the bedside so that providers connect data with their daily actions
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/appendicitis_research-protocol.pdf
December 09, 2013 - migration, anorexia, nausea, tenderness in RLQ, rebound pain,
elevated temperature, leukocytosis, and shift … guarding)
o Laboratory tests (e.g., white blood cell count, C-reactive protein
concentration, left shift … The grading will be
outcome specific, such that a given study that reports its primary outcome well … Surgeon-performed ultrasound at the
bedside for the detection of appendicitis and gallstones: systematic … Available at: http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-
and-reports/?
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digital.ahrq.gov/sites/default/files/docs/improve-medication-management-slides-091318.pdf
September 27, 2018 - • Complete bedside medication delivery form.
– Provide estimated date and time of discharge.
– Note … Role of Outpatient Providers
• Encouraged PCPs (or practice managers) to
review the adherence reports … arm patients.
– Proportion of regimen in pill trays.
– On-time delivery of trays.
– Use of adherence reports … • Former pharmacies may object to loss of business.
• Paradigm shift for patients and providers: regimen … Viewing Adherence Report
Adherence Report: Time Trends
Adherence Report: Dose Times
Role of Outpatient
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy1/Strat1_Tool_9_AdvisorTrain_508.docx
March 06, 2013 - Prepare for meetings as needed
by reviewing materials, reading a report,
or completing a task before … asked to help educate doctors, nurses, and other hospital staff about why it is important to conduct bedside … shift reports or involve patients and families in the discharge process. … statement
A list of hospital leaders and key personnel
Information on who patient and family advisors report
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psnet.ahrq.gov/perspective/conversation-christie-allen-about-maternal-safety-and-perinatal-mental-health
March 29, 2023 - quality improvement and patient safety, mostly from seeing gaps in care provided to patients at the bedside … Reports of the prevalence and incidence of these conditions vary; one study estimates that roughly 9% … A paradigm shift to address racial inequities in perinatal healthcare. … 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/hai/tools/ambulatory-surgery/sections/implementation/training-tools/pf-engagement-fac-notes.html
May 01, 2017 - Provider Bedside Manner
Health care providers who dismiss a patient’s or family member’s concerns or … Providing information about patient privacy in written preoperative materials, as well as sharing discharge summary … reports with the patient (and family members at the discretion of the patient). … ASC setting and a hospital surgery environment is that the responsibility of postoperative care may shift … Report to appropriate parties – Providers will use their facility’s policies to report adverse events
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy1/Strat1_Tool_9_AdvisorTrain_508.pdf
March 06, 2013 - • Prepare for meetings as needed
by reviewing materials, reading a report,
or completing a task … asked to
help educate doctors, nurses, and other hospital staff
about why it is important to conduct bedside … shift reports
or involve patients and families in the discharge process. … • A list of hospital leaders and key personnel
• Information on who patient and family advisors report
-
psnet.ahrq.gov/perspective/maternal-safety-and-perinatal-mental-health
March 28, 2023 - Reports of the prevalence and incidence of these conditions vary; one study estimates that roughly 9% … A paradigm shift to address racial inequities in perinatal healthcare. … quality improvement and patient safety, mostly from seeing gaps in care provided to patients 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
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www.ahrq.gov/sites/default/files/2025-03/chaudhry-report.pdf
January 01, 2025 - Final Progress Report: Yale Center for Healthcare Innovation, Redesign, and Learning (CHIRAL)
Final … Progress Report
Project Title: Yale Center for Healthcare Innovation, Redesign, and Learning (CHIRAL … Problem
analysis data were collected through observations (n=21), safety reports (n=25), semi-structured … transitions across providers and facilities, including the
introduction of structured interdisciplinary bedside … Final Progress Report
CHIRAL Center
Goals & Accomplishments
CHIRAL Administrative and Operations
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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
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/ps-research-summary-pfe.pdf
April 30, 2025 - /reports/engage/interventions/index.html
https://www.ahrq.gov/patient-safety/reports/engage/beprepared.html … reports/engage/medlist.html
https://www.ahrq.gov/patient-safety/reports/engage/teachback.html
https:/ … Patient and Families as Advisors
o Strategy 2: Communicating To Improve Quality
o Strategy 3: Nurse Bedside … Shift Report
o Strategy 4: IDEAL Discharge Planning
•Contains tools, materials, and training for each … family engagement in bedside rounds to improve the safety
of care provided to hospitalized children
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digital.ahrq.gov/sites/default/files/docs/publication/r01hs014947-porter-final-report-2007.pdf
January 01, 2007 - ParentLink: Better and Safer Emergency Care for Children
Grant Final Report
Grant ID: R01 HS014947 … information science; decision making; clinical decision
support systems
The authors of this report … Statements in the report should not
be construed as endorsement by the Agency for Healthcare Research … Relevant historical data elements for the disease topics of interest
that parents could report were … Otherwise, the output was
placed in the front of the patient’s bedside chart for physician review.
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www.ahrq.gov/sites/default/files/2025-04/schiff-mcnutt-report.pdf
January 01, 2025 - Final Progress Report: Cook County & Rush Developmental Center for Research in Patient Safety: Diagnosis … lost” as his diagnosis prematurely “closed” on
pneumonia when endorsed from the day to the night ED shift … Determining medical error: Three case reports. Effective
Clinical Practice 2002;5:23-8. … Incorporating the patient safety curriculum into your bedside
teaching. … Diagnostic Error Survey Preliminary Report.
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psnet.ahrq.gov/perspective/integrating-multiple-medication-decision-support-systems-how-will-we-make-it-all-work
May 01, 2008 - And then there was a shift 3 to 5 years ago, with a lot of literature about unintended consequences and … observed that one of the things that computerization does is de-tether the provider from the patient's 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
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psnet.ahrq.gov/node/49613/psn-pdf
November 01, 2010 - Develop bedside point-of-care bar code scanning, and support or champion other system
improvements that … Shift the paradigm from reactive risk management to proactive management. … Promptly report
results to parents. … 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