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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.
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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.
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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
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/overall-antibiotic-stewardship-project-final-report.pdf
September 01, 2022 - Detailed reports for each cohort1 as well as the setting-specific toolkits2,3 and implementation guides … staffing dimension (i.e., there are enough staff to handle the
workload, meet residents’ needs during shift … Many participating sites had to shift their staff and resources to
the pandemic which led to less time … Integrating bedside nurses into antibiotic stewardship: a
practical approach. … Issue 23;
June 20, 2019. https://www.jointcommission.org/-/media/tjc/documents/standards/r3-
reports
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www.ahrq.gov/hai/cusp/toolkit/content-calls/small-hospitals.html
April 01, 2013 - And you want to have those supplies readily available at the bedside, if possible, but certainly readily … You can use the tools and the transforming care at the bedside. … You do it with one patient for one shift with one nurse and see if it works, if it does work or you tweak … And I do put out a report card. … We have two patients per nurse, so usually we’ll have three nurses staff the shift.
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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
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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
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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
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/pf-engagement/pf-engagement-facnotes.docx
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).
· When possible, encourage … 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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effectivehealthcare.ahrq.gov/sites/default/files/related_files/mhs-IV-rapid-response-patient-family-engagement.pdf
October 01, 2023 - Safer IV – Patient and Family Engagement
staffed by its own group of nurses.23 The study integrated a bedside … which includes strategies for Patient and Family Advisory Councils,
improved communication, nurse bedside … shift reports, and discharge planning.8
• AHRQ’s Toolkit to Engage High-Risk Patients In Safe Transitions … except that patient fall prevention was mentioned but not highlighted in MHS III,
indicating a shift … https://oig.hhs.gov/oei/reports/OEI-06-18-00400.asp
https://oig.hhs.gov/oei/reports/OEI-06-18-00400.asp
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psnet.ahrq.gov/perspective/health-equity-and-maternal-health
October 06, 2021 - This shift can promote patient comprehension and the perception of healthcare as a resource for individuals … proficiency; patient-centered quality metrics, timing, and process; and more solutions, including a cultural shift … We've been chatting with folks about using Epic MyChart Bedside to deliver instructional materials to … 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-withalison-stuebe-md-msc-and-kristin-tully-phd
October 06, 2021 - We've been chatting with folks about using Epic MyChart Bedside to deliver instructional materials to … This shift can promote patient comprehension and the perception of healthcare as a resource for individuals … proficiency; patient-centered quality metrics, timing, and process; and more solutions, including a cultural 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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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/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
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/sppcii-hypertension-scenarios.pptx
July 01, 2023 - Severe Hypertension
I PASS the BATON
27
I PASS the BATON can be used during a nursing handoff at shift … Johnson asks Beth, the L&D bedside nurse, to start off the huddle. … Larsen, the anesthesiologist on the team, commends the L&D bedside nurse, Beth, for identifying Ms. … Smith’s bedside nurse, Beth, a quieter teammate, who hasn’t yet contributed her thoughts.
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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
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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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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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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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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