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361. From blaming to learning: re-framing organisational learning from adverse incidents. | PSNet
     psnet.ahrq.gov/issue/blaming-learning-re-framing-organisational-learning-adverse-incidents
     October 05, 2022 - March 21, 2017 Clinical deterioration as a nurse sensitive indicator in the out-of-hospital … April 1, 2019 Impact of high-reliability education on adverse event reporting by registered … nurses.

362. Do Me a Favor | PSNet
     psnet.ahrq.gov/web-mm/do-me-favor
     September 12, 2016 - The patient was a nurse who worked at the hospital and was friends with one of the obstetrics/gynecology … The charge nurse on the floor noticed that the bed in the antenatal testing room had been used. … Is this just a case of an overzealous charge nurse upset with two colleagues who violated "protocol" … Among the many personal anecdotes: nurses revealed that physicians often ask them for analgesics, antibiotics … Both doctors and nurses recounted professional requests for health care "favors" include taking blood

363. Wrong drug and wrong dose dispensing errors identified in pharmacist professional liability claims. | PSNet
     psnet.ahrq.gov/issue/wrong-drug-and-wrong-dose-dispensing-errors-identified-pharmacist-professional-liability
     August 31, 2016 - March 9, 2016 Distributed Cognition and the Role of Nurses in Diagnostic Safety in the … April 20, 2022 Systems-level factors affecting registered nurses during care of women … 2021 Reductions in sepsis mortality and costs after design and implementation of a nurse-based

364. Significant reduction in preanalytical errors for nonphlebotomy blood draws after implementation of a novel integrated specimen collection module. | PSNet
     psnet.ahrq.gov/issue/significant-reduction-preanalytical-errors-nonphlebotomy-blood-draws-after-implementation
     May 29, 2019 - Nurse worry predicts inpatient deterioration within 24 hours. … December 21, 2017 The effect of hospital electronic health record adoption on nurse-assessed … Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses … January 7, 2011 View More See More About The Topic Hospitals Nurses … Nurse Managers Information Professionals Pathology and Laboratory Medicine View More

365. Postdischarge Follow-Up Phone Call | PSNet
     psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call
     May 19, 2021 - For example, nurses recently discovered that a newly diagnosed diabetic was administering long-acting … Nurses also contacted a young patient who had been hospitalized with a new diagnosis of Crohn disease … An analysis of the 2240 phone calls made in 2011 at our institution found that nurses assisted patients … Nurses, pharmacists, and case managers have all been employed to make calls.( 6-8,16,18,19 ) Given that … Possible partners include nurses, physicians, case management, home care, primary care physicians, and

366. Fatigue amongst anaesthesiology and intensive care trainees in Europe: a matter of concern. | PSNet
     psnet.ahrq.gov/issue/fatigue-amongst-anaesthesiology-and-intensive-care-trainees-europe-matter-concern
     June 28, 2023 - March 27, 2013 Operational failures detected by frontline acute care nurses. … Call-shift fatigue and use of countermeasures and avoidance strategies by certified registered … nurse anesthetists: a national survey.

367. Mature rapid response system and potentially avoidable cardiopulmonary arrests in hospital. | PSNet
     psnet.ahrq.gov/issue/mature-rapid-response-system-and-potentially-avoidable-cardiopulmonary-arrests-hospital
     July 20, 2022 - February 6, 2012 Nurses' perceptions of simulation-based interprofessional training program … December 1, 2011 Nurses' perceptions of how rapid response teams affect the nurse, team … June 20, 2011 The role of the non-ICU staff nurse on a medical emergency team: perceptions … November 2, 2010 Rapid response teams seen through the eyes of the nurse.

368. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities | PSNet
     psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
     November 27, 2019 - The next pivotal event occurred when the nurse incorrectly selected the weight-based dosing strategy … the pediatric population to minimize the risk of error. 9  Education and training for physicians, nurses … Furthermore, requiring nurses to perform independent verification with another nurse prior to exceeding … Once mitigation strategies are deployed, education and training efforts with nurses, physicians, and … September 1, 2016 WebM&M Cases Nurse Staffing Ratios:

369. Implementing standardized reporting and safety checklists. | PSNet
     psnet.ahrq.gov/issue/implementing-standardized-reporting-and-safety-checklists
     September 29, 2017 - An educational intervention increased nurses' knowledge of the SBAR communication tool. … September 14, 2022 Workplace verbal abuse, nurse-reported quality of care, and patient … safety outcomes among early-career hospital nurses. … September 12, 2018 Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician … Nurse Managers Quality and Safety Professionals Educators View More

370. Detection of patient risk by nurses: a theoretical framework. | PSNet
     psnet.ahrq.gov/issue/detection-patient-risk-nurses-theoretical-framework
     September 24, 2010 - Commentary Detection of patient risk by nurses: a theoretical framework. … Detection of patient risk by nurses: a theoretical framework. … Detection of patient risk by nurses: a theoretical framework. … Improving Diagnostic Safety and Quality April 26, 2023 Nurse … Nurse Managers Risk Managers Safety Scientists View More

371. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33596/psn-pdf
     January 29, 2025 - Staffing levels and education, including establishing appropriate minimum physician and nurse staffing … levels, improving work environments, encouraging and facilitating advanced training of nurses, and … Medical emergency and rapid response teams (RRTs), including nurse-led teams with intensivist physician … This measure, sometimes referred to as "failure-to-rescue—nursing," was shown to be associated with nurse … staffing and skill mix, and was ultimately endorsed by the National Quality Forum as a nurse-sensitive

372. Perceptions of providing safe care for frail older people at home: a qualitative study based on focus group interviews with home care staff. | PSNet
     psnet.ahrq.gov/issue/perceptions-providing-safe-care-frail-older-people-home-qualitative-study-based-focus-group
     July 29, 2020 - August 10, 2022 The work of nurses to provide good and safe services to children receiving … hospital-at-home: a qualitative interview study from the perspectives of hospital nurses and physicians … June 1, 2012 View More Related Resources Registered nurses' efforts … hospital-at-home: a qualitative interview study from the perspectives of hospital nurses and physicians … July 21, 2021 Communication on safe caregiving between community nurse case managers

373. Misplaced Nasogastric Tube Resulting in Aspiration | PSNet
     psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
     August 01, 2009 - During nursing shift change, the incoming nurse was told that the NG tube was ready for use. … esophageal stricture, due to the risk of esophageal perforation. 2 The procedure is most often performed by nurses … tubes according to multiple guidelines, including the American College of Gastroenterology, Emergency Nurses … and between nurses at change of shift. … Similarly, nurses could measure NG tube aspirate pH for newly placed NG tubes as an additional checkpoint

374. Priority patient safety issues identified by perioperative nurses. | PSNet
     psnet.ahrq.gov/issue/priority-patient-safety-issues-identified-perioperative-nurses
     June 19, 2013 - Study Priority patient safety issues identified by perioperative nurses. … Priority patient safety issues identified by perioperative nurses. … Priority patient safety issues identified by perioperative nurses. … May 13, 2020 Nurse judgements of hospitalized patients' safety concerns are affected … by patient, nurse and event characteristics: a factorial survey experiment.

375. Ensuring effective care transition communication: implementation of an electronic medical record-based tool for improved cancer treatment handoffs between clinic and infusion nurses. | PSNet
     psnet.ahrq.gov/issue/ensuring-effective-care-transition-communication-implementation-electronic-medical-record
     July 12, 2023 - electronic medical record-based tool for improved cancer treatment handoffs between clinic and infusion nurses … Electronic Medical Record-Based Tool for Improved Cancer Treatment Handoffs Between Clinic and Infusion Nurses … electronic health record tool designed to improve the handoff between oncology clinic and infusion nurses … October 19, 2011 Health IT implementation stories: HANDS care plan tool seeks to improve nurse … Nurse Managers Information Professionals Medical Oncology View More

376. A Tale of Two Falls | PSNet
     psnet.ahrq.gov/web-mm/tale-two-falls
     March 27, 2024 - While the clinician was relaying the care plan to the nurse at the nurses’ station, a thud was heard. … The receiving nurse asked the transport team and attempted to contact the ED nurse about the indication … nurse during a patient’s transition in care, which did not allow the receiving nurse to question the … For example, in Case #2, the receiving nurse could have used secure chat to ask the ED nurse for clarifying … Of course, there is some risk in relying on the EHR for important communication, as nurses may correctly

377. Communication and teamwork in patient care: how much can we learn from aviation? | PSNet
     psnet.ahrq.gov/issue/communication-and-teamwork-patient-care-how-much-can-we-learn-aviation
     August 12, 2019 - August 27, 2012 Effective physician–nurse communication: a patient safety essential for … February 3, 2011 Nurse-physician communication during labor and birth: implications for … View More See More About The Topic Labor and Delivery Physicians Nurses … Nurse Managers Quality and Safety Professionals View More

378. When medical error becomes personal, activism becomes painful. | PSNet
     psnet.ahrq.gov/issue/when-medical-error-becomes-personal-activism-becomes-painful
     August 21, 2019 - July 27, 2022 Reinforcing the Value and Roles of Nurses in Diagnostic Safety: Pragmatic … Recommendations for Nurse Leaders and Educators. … September 21, 2022 Nurse Vaught sentenced for deadly medical error. … Topic General Public Hospitals Health Care Executives and Administrators Medicine Nurse

379. Psychological safety in intensive care unit rounding teams. | PSNet
     psnet.ahrq.gov/issue/psychological-safety-intensive-care-unit-rounding-teams
     May 05, 2021 - February 20, 2019 Strategies used by critical care nurses to identify, interrupt, and … Moral distress, compassion fatigue, and perceptions about medication errors in certified critical care nurses … October 26, 2011 Impact of performance obstacles on intensive care nurses' workload, … January 19, 2011 Structural empowerment and patient safety culture among registered nurses … November 3, 2010 Worries and concerns experienced by nurse specialists during inter-hospital

380. Keeping Patients Safe: Transforming the Work Environment of Nurses. | PSNet
     psnet.ahrq.gov/issue/keeping-patients-safe-transforming-work-environment-nurses
     July 05, 2016 - Classic Keeping Patients Safe: Transforming the Work Environment of Nurses … Citation Text: Keeping Patients Safe: Transforming the Work Environment of Nurses. … Page A; Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services … in Diagnostic Safety: Pragmatic Recommendations for Nurse Leaders and Educators. … Facility and Group Administrators Nurse Managers View More