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psnet.ahrq.gov/node/44171/psn-pdf
May 27, 2015 - Professionalism in medicine is considered an essential component of safety culture, but efforts to monitor
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psnet.ahrq.gov/node/851099/psn-pdf
June 28, 2023 - Display arterial and central venous pressures on the monitor
Displaying the pressure measured at the … tip of the catheter on the monitor will help identify if the catheter is
in an artery or a vein. … The stopcock on a three way tap in the line can be turned while looking at the
pressure trace on the monitor … Continuously monitor skin color and perfusion of the limb distal to the arterial line
This patient complained … Arterial and central line pressure traces should be displayed on the monitor.
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psnet.ahrq.gov/node/74178/psn-pdf
December 15, 2021 - including using analytic approaches in patient safety research, measurement, and practice
improvement to monitor
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psnet.ahrq.gov/issue/proceedings-summit-preventing-patient-harm-and-death-iv-medication-errors
June 16, 2019 - December 30, 2014
Implementation of a specialized pharmacy team to monitor high-risk
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psnet.ahrq.gov/node/36947/psn-pdf
September 09, 2011 - Approximately one-third of the errors were considered preventable, primarily due to failure
to adequately monitor
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psnet.ahrq.gov/node/848124/psn-pdf
April 26, 2023 - The engineer mapped the existing workflow of nurses at the bedside and thought about
how the monitor … For instance, we added wireless patient sensors that collect
vital signs with the monitor and enter … 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
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psnet.ahrq.gov/node/74121/psn-pdf
November 30, 2021 - All monitor alarm functions were silenced to
help the patient rest until a bed became available on the … https://psnet.ahrq.gov//#10
https://psnet.ahrq.gov/issue/insights-problem-alarm-fatigue-physiologic-monitor-devices-comprehensive-observational-study … https://psnet.ahrq.gov/issue/insights-problem-alarm-fatigue-physiologic-monitor-devices-comprehensive-observational-study … psnet.ahrq.gov/primer/alert-fatigue
https://psnet.ahrq.gov/issue/insights-problem-alarm-fatigue-physiologic-monitor-devices-comprehensive-observational-study … Insights into the problem of alarm fatigue with
physiologic monitor devices: a comprehensive observational
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psnet.ahrq.gov/node/43398/psn-pdf
July 30, 2014 - This guideline offers an overview of
evidence-based strategies to monitor and promote hand hygiene,
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psnet.ahrq.gov/node/43162/psn-pdf
June 16, 2014 - use-report-cards-and-outcome-measurements-improve-safety-surgical-care-
american-college
The National Surgical Quality Improvement Program (NSQIP) was developed to monitor
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psnet.ahrq.gov/node/41606/psn-pdf
February 01, 2019 - particularly important safety issues, calls for
hospitals to implement standardized methods to assess and monitor
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psnet.ahrq.gov/node/47673/psn-pdf
January 09, 2019 - The authors highlight the need to better monitor
diagnostic error in the emergency department to inform
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psnet.ahrq.gov/node/45965/psn-pdf
April 19, 2017 - use of the Global Trigger Tool with a two-stage retrospective review process
to design a method to monitor
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psnet.ahrq.gov/node/49731/psn-pdf
April 01, 2015 - 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/issue/reducing-falls-safety-spotter-program
November 16, 2022 - employed "spotters" to watch and interact with patients at risk for falls, with one spotter assigned to monitor
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psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
January 29, 2021 - Display arterial and central venous pressures on the monitor Displaying the pressure measured at the … tip of the catheter on the monitor will help identify if the catheter is in an artery or a vein. … The stopcock on a three way tap in the line can be turned while looking at the pressure trace on the monitor … Continuously monitor skin color and perfusion of the limb distal to the arterial line This patient complained … Arterial and central line pressure traces should be displayed on the monitor.
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psnet.ahrq.gov/issue/lessons-learned-medical-malpractice-claims-involving-critical-care-nurses
July 15, 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/issue/healthcare-complaints-analysis-tool-development-and-reliability-testing-method-service
November 29, 2023 - Application of this framework could help health care organizations appropriately monitor and learn from
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psnet.ahrq.gov/node/44971/psn-pdf
June 01, 2016 - commentary describes how one multidisciplinary cancer center designed and
applied a taxonomy to report and monitor
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psnet.ahrq.gov/node/45256/psn-pdf
July 01, 2017 - this commentary describes a tested incident assessment framework that
employs charting mechanisms to monitor
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psnet.ahrq.gov/issue/implementation-science-ambulatory-care-safety-novel-method-develop-context-sensitive
April 17, 2019 - engineering and design thinking approaches to develop an understanding of how ambulatory specialists monitor