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www.ahrq.gov/hai/cusp/cusp-success/peterson.html
September 01, 2012 - Theresa Hickman, RN, an ICU nurse, manager, and educator, was asked to lead its implementation because … Members included Saul, an ICU nurse, the Director of Quality Services, and a quality analyst. … Initially, Hickman and the ICU's Nurse Director led the CUSP Team. … Like Hickman, Morris was enthusiastic about how CUSP had enhanced nurse-to-nurse and nurse-doctor communication … “When she sees that a patient can be harmed, any nurse can formally fix that.”
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www.ahrq.gov/news/newsletters/e-newsletter/768.html
June 01, 2021 - Study Examines Impact of Monitoring Alarms on Nurse Workload
Issue Number
768
AHRQ News Now … Today's Headlines:
Study Examines Impact of Monitoring Alarms on Nurse Workload . … Study Examines Impact of Monitoring Alarms on Nurse Workload
Increased exposure to patient monitoring … Safety Learning Laboratory funded by AHRQ that aimed to reduce noninformative alarms and accelerate nurses … The study found that nurses exposed to 40 or more alarms within a two-hour period experienced a 5.5 point
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www.ahrq.gov/hai/tools/perinatal-care/modules/teamwork/assemble-fac-guide.html
May 01, 2017 - ,managers, midwives, anesthetists,nurse practitioners, and L&D staff nurses. … For example, a nurse opinion leader can serve as the representative for all L&D unit nurses on the CUSP … of the L&D unit nurses at CUSP team meetings. … The nurse manager supports CUSP activities by communicating the team's needs to the L&D unit nurses. … contact for the L&D unit nurses, helps empower the unit nurses throughout the initiative, and integrates
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www.ahrq.gov/sites/default/files/publications/files/dischargeprep.docx
January 02, 2013 - : (Name of patient’s nurse)
Date: _______ Nurse: __________
Date: _______ Nurse: __________ … Date: _______ Nurse: __________
Date: _______ Nurse: __________
Date: _______ Nurse: ________ … __
Date: _______ Nurse: __________
Date: _______ Nurse: __________
Date: _______ Nurse: _ … Nurse: __________
Date: _______ Nurse: __________
Date: _______ Nurse: __________
Date: … _______ Nurse: __________
Date: _______ Nurse: __________
Date: _______ Nurse: __________
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/red/toolkit/dischargeprep.docx
January 02, 2013 - : (Name of patient’s nurse)
Date: _______ Nurse: __________
Date: _______ Nurse: __________ … Date: _______ Nurse: __________
Date: _______ Nurse: __________
Date: _______ Nurse: ________ … __
Date: _______ Nurse: __________
Date: _______ Nurse: __________
Date: _______ Nurse: _ … Nurse: __________
Date: _______ Nurse: __________
Date: _______ Nurse: __________
Date: … _______ Nurse: __________
Date: _______ Nurse: __________
Date: _______ Nurse: __________
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-survey-english.pdf
September 01, 2024 - Administrator
Medical Director
Director of Nursing/Nursing Supervisor
Department Head
Unit Manager/Charge Nurse … Assistant Director/Assistant Manager
Minimum Data Set (MDS) Coordinator/
Resident Nurse Assessment … Other Provider
Nurse Practitioner
Clinical Nurse Specialist
Physician Assistant
d. … Licensed Nurse
Registered Nurse (RN)
Licensed Practical Nurse (LPN)
Wound Care Nurse
e.
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/2023-ASC-Database-Report-II.pdf
January 01, 2023 - incidents were “Always” or “Most of the time”
documented in an incident or occurrence report (98 percent); Nurses … follows:
• Anesthesiologist
• Doctor/Physician (excluding Anesthesiologists) or Surgeon
• Certified Registered … Nurse Anesthetist (CRNA)
• Physician Assistant or Nurse Practitioner
• Management: Medical Director … , Office Manager, Other Manager
• Nurse: Registered Nurse (RN), Licensed Practical Nurse (LPN)/Licensed … In addition, those who worked 17 to 31 hours per
week were primarily nurses, and those who worked more
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www.ahrq.gov/hai/cauti-tools/cauti-icu/facil-guide/mod3-slides.html
February 01, 2023 - protocol for catheter removal
Day nurse Sally and Ms. … X
Image: To the right of text are images of "Nurse Sally" and "Mrs. X." … X
Image: Photo on right side of slide of "Nurse Molly." … Images: Photo of "Nurse Sally" and "Nurse Molly." … Slide 10
The Manager's Reaction
Images: Photos of the "Nurse Manager" and "Nurse Molly."
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www.ahrq.gov/sites/default/files/publications/files/dischargeprep.pdf
February 14, 2013 - : (Name of patient’s nurse)
Date: _______ Nurse: __________
Date: _______ Nurse: _______ … ___
Date: _______ Nurse: __________
Date: _______ Nurse: __________
Date: _______ Nurse … : __________
Date: _______ Nurse: __________
Date: _______ Nurse: __________
Date: … Date: _______ Nurse: __________
Date: _______ Nurse: __________
Date: _______ Nurse … ______ Nurse: __________
Date: _______ Nurse: __________
Date: _______ Nurse: _________
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/red/toolkit/dischargeprep.pdf
February 14, 2013 - : (Name of patient’s nurse)
Date: _______ Nurse: __________
Date: _______ Nurse: _______ … ___
Date: _______ Nurse: __________
Date: _______ Nurse: __________
Date: _______ Nurse … : __________
Date: _______ Nurse: __________
Date: _______ Nurse: __________
Date: … Date: _______ Nurse: __________
Date: _______ Nurse: __________
Date: _______ Nurse … ______ Nurse: __________
Date: _______ Nurse: __________
Date: _______ Nurse: _________
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/prescribers-slides.pptx
June 01, 2021 - improve communication between nursing staff and providers
Recognize that SBAR can support the role of nurses … suggest a time frame
6
Communicating With Prescribers
6
SBAR To Improve Communication
Nearly 90% of nurses … No The nurse did not share:
Resident’s anticoagulation status
No update on vitals
Clear? … Tell the nurse to wait until Monday and notify the regular practitioner. “I’m too busy right now.” … His nurse faxes the urine culture results to provider’s office.
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www.ahrq.gov/news/newsletters/e-newsletter/945.html
February 01, 2025 - Better Nurse Staffing Levels Associated With Lower Rates of Cesarean Section
Issue Number
945 … Today's Headlines: Better Nurse Staffing Levels Associated With Lower Rates of Cesarean Section . … nurse staffing levels led to lower cesarean section (C-section) rates and higher vaginal birth after … Researchers examined the impact of nurse staffing levels during labor on rates of C-section and VBAC … The study examined data including 2,786 nurses across 193 hospitals in 23 states.
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www.ahrq.gov/patient-safety/capacity/candor/modules/guide4/apb.html
February 01, 2017 - Analysis Guide: Appendix B
Event Type:
Individuals Interviewed:
NAME
TITLE/ROLE
Nurse … #1
Charge nurse
Nurse #2
RN
CNA X
Nursing tech
Manager MS
Manager
Pertinent Interview … Nurse #1 and Nurse #2 both said they were speaking to the tech at the same time while she was passing … The CNA referred to both of the patients as "your patient" when providing each nurse with results. … There was an opportunity to ask a clarifying question of the tech and nurses about patient identification
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kline_32.pdf
March 03, 2008 - Collaborate with nurse leader, clinical nurse specialist, or nursing
supervisor to determine the need … Departmental nursing
leadership identified six
individuals from the
unit—including registered
nurses … The unit-
based nurse leader, nurse
3. … The registered nurse delegates
tasks depending on the needs and condition of the patient, the complexity … The nurse leader and clinical nurse specialist on the unit review every patient fall according to
the
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www.ahrq.gov/teamstepps/rrs/rrsspecscen.html
October 01, 2014 - The family member alerted the nurse about these concerns. … The nurse assured the family member that she would check on the patient. … An hour later, the family member reminded the nurse, who then assessed the patient. … The nurse checked the patient’s vital signs. … Based on her colleague’s recommendation, the nurse called the RRT via the operator.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemaking.pptx
January 01, 2006 - unclear about procedure
Temp nurses need help
Other nurses on sick-out
Group O patient almost given … Group A Blood
A positive unit was hanging on the infuser
Transfusing nurse didn’t check blood type on … hanging unit
A positive unit not removed from prior case
Nurse was busy and distracted
Nurse interrupts … transfusion
Nurse sees that unit is A positive
Recovery
Antecedent Events
Root Causes
Discovery Event … OK
OM
HEX
Nurse was busy and distracted
Temp nurse unclear about procedure
CUSP and Sensemaking: Next
-
www.ahrq.gov/sites/default/files/2024-04/baernholdt-report.pdf
January 01, 2024 - Additionally, context
(community, hospital, and nursing unit characteristics), nurse work environment … nurse staffing, rural, urban, longitudinal
2
2. … Specific Aim 2: To examine the effect nurse work environment (NWE) factors and nurse
outcomes have on … Likert scale in which
higher scores represent higher
satisfaction
Intent to leave Percentage of nurses … The rural nurses
scored their practice environment and job satisfaction lower, but their intent-to-leave
-
www.ahrq.gov/research/findings/final-reports/stpra/stpraapd3.html
April 01, 2018 - Anesthesiologist and nurse take to PACU. Anesthesiologist is at head and nurse is at foot. … Circulating nurse take to PACU. … In PACU nurses are gloved, not gowned. … Patient to nurse ratio in PACU
2 patients to1 nurse, critical care is 1 to 1. … PACU nurses call every patient next day and ask about any problems or unexpected things.
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www.ahrq.gov/teamstepps-program/curriculum/mutual/tools/index.html
June 01, 2023 - Long-term care
Have an experienced registered nurse offer to administer routine medications for a less … experienced registered nurse who is behind in their care because of a patient whose condition was deteriorating
-
www.ahrq.gov/hai/cauti-tools/facil-guide/preventing-cauti-icu-setting-module3-speaker-notes.html
February 01, 2023 - nurse. … She implemented the nurse-driven protocol because there was no need for hourly output measurement. … X and instructed her on how to call the nurse when the bedpan was needed. … Molly was an experienced nurse and had worked in the ICU for 15 years. … Nurses are busy, and for many nurses, removing a catheter is a change in practice. Clearly, Ms.