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9821. Discharge Instructions in the PACU: Who Remembers? | PSNet
      psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers
      August 05, 2009 - highly-structured approaches to the discharge process that involve numerous supporting elements, including nurse … Nurse–patient/visitor communication in the emergency department. J Emerg Nurs. 2009;35:406-411.

9822. Add-on Case and the Missing Checklist | PSNet
      psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
      September 01, 2012 - When the endoscopy suite called for the patient, the bedside nurse said that the patient had just had … While performing the preanesthesia checklist, the certified nurse anesthetist documented that enoxaparin

9823. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49660/psn-pdf
      August 01, 2012 - The Case A 10-year-old girl with a history of asthma was brought by her mother (a nurse) to see a pediatrician … customizing alerts to prevent alert fatigue • A population-based view that allows clinicians and/or nurse

9824. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49470/psn-pdf
      December 01, 2004 - family doctor to let her know the likely problems that will develop, and arranging home visits by a nurse … In-hospital case management with intensive nurse follow-up has been demonstrated to reduce hospital

9825. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49455/psn-pdf
      July 01, 2004 - She had presented to clinic later that day, where a nurse practitioner assessed her symptoms as consistent … We are not told how the nurse practitioner "assessed her symptoms as consistent with her prior migraines

9826. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49462/psn-pdf
      October 01, 2004 - example, I recently asked for an E-cylinder of oxygen to transport a critically ill patient, and the nurse … The nurse had inadvertently brought a CO2 cylinder (gray in color) instead of an oxygen cylinder.

9827. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846768/psn-pdf
      March 29, 2023 - However, while the team was moving him from the OR table to the gurney, a nurse inadvertently pulled … breathing circuit before transferring an intubated patient This patient’s ETT was dislodged because the nurse

9828. Too Tight Control | PSNet
      psnet.ahrq.gov/web-mm/too-tight-control
      March 20, 2013 - In one study, the wound infection rate was reduced from 3% to 1% using a nurse-managed IV insulin protocol … At 2 am, when the nurse came to measure the hourly fingerstick, she found the patient somnolent, tremulous

9829. One group of doctors changes its ways. | PSNet
      psnet.ahrq.gov/issue/one-group-doctors-changes-its-ways
      February 04, 2015 - Citation Related Resources From the Same Author(s) Healthcare Safety for Nursing … Personnel: An Organizational Guide to Achieving Results.

9830. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33696/psn-pdf
      June 01, 2010 - just thinking errors, they're also affective errors—errors that arise when physicians' feelings or nurses … For example, if a nurse or a colleague comes to you and says, "Oh, so and so is here. … aberrant presentations, or if you're aware of patients labeling themselves, or of colleagues, triage nurses … When nurses ask me the discharge diagnosis on the patient and I say it's "chest pain not yet diagnosed

9831. In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety | PSNet
      psnet.ahrq.gov/perspective/conversation-timothy-vogus-about-high-reliability-organization-hro-principles-and
      February 26, 2025 - At the start of a shift, instead of doing handoffs about individual patients, nurses do an overall briefing … on interviews with hospital executives, program leaders, staff, and physicians, the study found that nurses … Finally, a study on pursuing highly reliable performance among nurses in three Midwestern acute-care

9832. High Reliability Organization (HRO) Principles and Patient Safety | PSNet
      psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
      February 26, 2025 - on interviews with hospital executives, program leaders, staff, and physicians, the study found that nurses … Finally, a study on pursuing highly reliable performance among nurses in three Midwestern acute-care … At the start of a shift, instead of doing handoffs about individual patients, nurses do an overall briefing

9833. IHI Fellowship Program. | PSNet
      psnet.ahrq.gov/issue/ihi-fellowship-program
      December 13, 2017 - November 25, 2020 DAISY Award for Extraordinary Nurses in Patient Safety.

9834. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60328/psn-pdf
      May 27, 2020 - opioid-induced respiratory depression, deaths most frequently occur overnight between 00:00-06:00 am when nurse … RN Postdoctoral Research Fellow, Division of Pulmonary, Critical Care and Sleep Medicine Clinical Nurse … Avoiding Adverse Events Secondary to Opioid-Induced Respiratory Depression: Implications for Nurse Executives

9835. AHRQ PSNet Webinar (pdf file)
      psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
      January 01, 2025 - Primary Removed hospitalist physician, added critical care nurse Hospital Standardized Mortality … Primary Changed from nurse led team to physician led Incidence of cardiorespiratory arrest 2.2 … • 4 non-randomized studies • Combination of opioid education to prescribers, academic detailing, nurse

9836. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866727/psn-pdf
      September 18, 2024 - Pharmacists gave more unfavorable scores to EHR usability compared to nurses.

9837. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected | PSNet
      psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
      September 25, 2024 - September 25, 2024 Hospital nurses' perceptions of human factors contributing to nursing … July 7, 2021 Registered nurses' and medical doctors' experiences of patient safety in

9838. Glossary | PSNet
      psnet.ahrq.gov/glossary
      January 01, 2003 - orthopedist operating on the wrong leg) or figuratively be administering any kind of therapy (e.g., a nurse … penicillin allergy receives penicillin, but has no reaction) or a fortuitous, timely intervention (e.g., a nurse … Nurses, junior medical staff, or others involved in the care of patients can call for the assistance … penicillin allergy receives penicillin, but has no reaction) or a fortuitous, timely intervention (e.g., a nurse … orthopedist who operates on the wrong leg) or figuratively be administering any kind of therapy (e.g., a nurse

9839. Glossary | PSNet
      psnet.ahrq.gov/glossary-0
      January 01, 2003 - orthopedist operating on the wrong leg) or figuratively be administering any kind of therapy (e.g., a nurse … penicillin allergy receives penicillin, but has no reaction) or a fortuitous, timely intervention (e.g., a nurse … Nurses, junior medical staff, or others involved in the care of patients can call for the assistance … penicillin allergy receives penicillin, but has no reaction) or a fortuitous, timely intervention (e.g., a nurse … orthopedist who operates on the wrong leg) or figuratively be administering any kind of therapy (e.g., a nurse

9840. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47560/psn-pdf
      January 09, 2019 - participation, frontline engagement, and more frequent activities for all involved groups, including surgeons, nurses