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psnet.ahrq.gov/node/60758/psn-pdf
August 05, 2020 - departments and operating rooms, ICU
nurses were likely to have a malpractice claim alleging failure to monitor
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psnet.ahrq.gov/web-mm/fire-hole-or-fire
August 03, 2017 - large 3-liter bag of irrigating solution from the handle of the anesthesiologists' accessory "slave" monitor … Suddenly, sparks and flames began shooting from the monitor tower, and the OR quickly filled with black … Once it was extinguished and the monitor setup examined, the culprit was identified: the leaking bag … tracheal surgery.( 7 )
Fire in the Presented Case
The ignition source in the presented case (i.e., the monitor
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psnet.ahrq.gov/node/837031/psn-pdf
May 04, 2022 - This study aimed to
develop a set of “implementation patient safety indicator(s) sets” to monitor the
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psnet.ahrq.gov/node/842769/psn-pdf
January 18, 2023 - sociotechnical systems and discusses the need for
future research to develop and implement systems to monitor
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psnet.ahrq.gov/node/73627/psn-pdf
January 01, 2022 - https://psnet.ahrq.gov/issue/my-five-moments-hand-hygiene-user-centred-design-approach-understand-train-monitor-and-report
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psnet.ahrq.gov/node/838914/psn-pdf
October 26, 2022 - Health Administration’s National Center for Patient Safety established two
working groups to rapidly monitor
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psnet.ahrq.gov/node/837504/psn-pdf
June 22, 2022 - identifying-unintended-consequences-quality-indicators-qualitative-study
https://psnet.ahrq.gov/issue/analysis-structure-and-content-dashboards-used-monitor-patient-safety-inpatient-setting
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psnet.ahrq.gov/node/836986/psn-pdf
April 27, 2022 - https://psnet.ahrq.gov/primer/alert-fatigue
https://psnet.ahrq.gov/perspective/reducing-safety-hazards-monitor-alert-and-alarm-fatigue
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psnet.ahrq.gov/node/853610/psn-pdf
September 20, 2023 - alert-fatigue
https://psnet.ahrq.gov/issue/video-analysis-factors-associated-response-time-physiologic-monitor-alarms-childrens-hospital
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psnet.ahrq.gov/node/851650/psn-pdf
July 26, 2023 - temporal-clustering-critical-illness-events-medical-wards
https://psnet.ahrq.gov/primer/failure-rescue
https://psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults-risk-hospital
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psnet.ahrq.gov/node/60730/psn-pdf
January 01, 2021 - machine-learning-approach-reclassifying-miscellaneous-patient-safety-event-
reports
Health systems rely on accurate event reporting to monitor
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psnet.ahrq.gov/issue/improving-patient-care-through-safe-health-it
August 12, 2020 - summarizes expert opinion on the role of system usability in patient safety, and describes an approach to monitor
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psnet.ahrq.gov/node/855432/psn-pdf
November 15, 2023 - https://psnet.ahrq.gov/primer/alert-fatigue
https://psnet.ahrq.gov/perspective/reducing-safety-hazards-monitor-alert-and-alarm-fatigue
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psnet.ahrq.gov/node/864376/psn-pdf
March 13, 2024 - This qualitative study evaluated the
implementation of ‘WardSonar,’ a tool designed to digitally monitor
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psnet.ahrq.gov/node/839827/psn-pdf
December 20, 2020 - triage patients, initiate or adjust oxygen administration, and, more recently, as a
way to remotely monitor
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psnet.ahrq.gov/node/36548/psn-pdf
March 03, 2011 - when-good-doctors-go-bad-systems-problem
The author discusses the responsibilities of physicians to help monitor
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psnet.ahrq.gov/node/50621/psn-pdf
November 06, 2019 - team-based-intervention-reduce-impact-nonactionable-alarms-adult-intensive-care-unit
https://psnet.ahrq.gov/issue/insights-problem-alarm-fatigue-physiologic-monitor-devices-comprehensive-observational-study
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psnet.ahrq.gov/node/60225/psn-pdf
April 15, 2020 - healthcare principles (described as systems that anticipate future
demands, respond to current demands, monitor
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psnet.ahrq.gov/node/74265/psn-pdf
January 19, 2022 - review of prenatal records,
missed timely documentation of maternal-fetal assessments, and failure to monitor
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psnet.ahrq.gov/node/72496/psn-pdf
November 25, 2020 - psnet.ahrq.gov/issue/national-drug-shortages-worsen-during-covid-19-crisis-proposal-comprehensive-model-monitor