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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/46071/psn-pdf
March 20, 2018 - Examining tools to monitor situation awareness
among nurses, this review determined that measures to
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psnet.ahrq.gov/node/46789/psn-pdf
March 20, 2018 - seeing-through-google-glass-using-innovative-technology-improve-medication-safety-behaviors
https://psnet.ahrq.gov/perspective/reducing-safety-hazards-monitor-alert-and-alarm-fatigue
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psnet.ahrq.gov/node/842779/psn-pdf
January 12, 2011 - resilience-engineering-practice-guidebook
Safety-critical industries rely on organizational aptitude to respond to disruptions, monitor
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psnet.ahrq.gov/node/43879/psn-pdf
February 04, 2015 - https://psnet.ahrq.gov/issue/complaints-and-raising-concerns
Complaints are a proactive way to monitor
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psnet.ahrq.gov/node/44695/psn-pdf
June 07, 2016 - surgical time-outs where scanning a patient's wristband
launches a presentation on the operating room monitor
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psnet.ahrq.gov/node/46422/psn-pdf
November 29, 2017 - psnet.ahrq.gov/issue/framework-direct-observation-performance-and-safety-healthcare
Efforts to measure and monitor
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psnet.ahrq.gov/node/37979/psn-pdf
April 11, 2011 - preliminary-assessment-pediatric-health-care-quality-and-patient-safety-united-
states-using
This article discusses the development of indicators to monitor
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psnet.ahrq.gov/node/36671/psn-pdf
January 18, 2011 - increasing-vigilance-medicalsurgical-floor-improve-patient-safety
The authors describe an automated, non-invasive technology used to monitor
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psnet.ahrq.gov/node/37349/psn-pdf
January 06, 2012 - disruptions-surgical-flow-and-their-relationship-surgical-errors-exploratory-
investigation
Using a trained observer to monitor
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psnet.ahrq.gov/perspective/conversation-susan-mcgrath-phd-and-george-blike-md-about-surveillance-monitoring
April 26, 2023 - The engineer mapped the existing workflow of nurses at the bedside and thought about how the monitor … It’s not to say that you shouldn’t monitor other physiologic parameters like respiratory rate, but you … By all means, monitor other things, but if you’re building the airbag, you should only be alarming on … We have a very highly reliable pulse oximetry system and continue to monitor its performance over time … Monitor alarm fatigue: an integrative review.
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psnet.ahrq.gov/node/45869/psn-pdf
March 25, 2017 - data-driven-implementation-alarm-reduction-interventions-cardiovascular-surgical-icu
https://psnet.ahrq.gov/issue/insights-problem-alarm-fatigue-physiologic-monitor-devices-comprehensive-observational-study
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psnet.ahrq.gov/node/44706/psn-pdf
November 25, 2015 - errors-associated-outpatient-computerized-prescribing-systems
https://psnet.ahrq.gov/issue/development-and-pilot-testing-guidelines-monitor-high-risk-medications-ambulatory-setting
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psnet.ahrq.gov/node/47224/psn-pdf
June 27, 2018 - psnet.ahrq.gov/primer/alert-fatigue
https://psnet.ahrq.gov/issue/insights-problem-alarm-fatigue-physiologic-monitor-devices-comprehensive-observational-study
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psnet.ahrq.gov/node/848125/psn-pdf
April 26, 2023 - psnet.ahrq.gov//#_edn10
https://psnet.ahrq.gov/issue/association-between-exposure-nonactionable-physiologic-monitor-alarms-and-response-time … Another
https://psnet.ahrq.gov/perspective/reducing-safety-hazards-monitor-alert-and-alarm-fatigue
https … Monitor alarm fatigue: an integrative review. Biomed Instrument Technol. 2012;46(4):268-
277.
12.
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psnet.ahrq.gov/node/61042/psn-pdf
January 01, 2022 - policies for patient identification throughout the continuum of care, (2) develop policies to report and
monitor
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psnet.ahrq.gov/node/46743/psn-pdf
January 17, 2018 - 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/37794/psn-pdf
February 15, 2011 - how the AHRQ Hospital Survey on Patient Safety Culture can be used to drive
initiatives, measure and monitor
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psnet.ahrq.gov/node/44787/psn-pdf
January 20, 2016 - overrides-medication-related-clinical-decision-support-alerts-outpatients
https://psnet.ahrq.gov/issue/wolf-crying-operating-room-patient-monitor-and-anesthesia-workstation-alarming-patterns
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psnet.ahrq.gov/node/43749/psn-pdf
December 10, 2014 - nursing staff about areas for improvement and performing direct
observations in patient care settings to monitor