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9801. 2019 Nursing Home SOPS Culture Executive Summary (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/2019-nhsops-dbreport-execsumm.pdf
      January 01, 2019 - 2019 Nursing Home SOPS Culture Executive Summary Executive Summary Full report: https://www.ahrq.gov/sops/databases/nursing-home/index.html Data Submission Information: https://www.ahrq.gov/sops/databases/nursing- home/databases/submission.html Pub. No. 19-0027-01 February 2019 https://www.ahrq.gov/sops/databa…

9802. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.278_slideshow.ppt
      September 01, 2012 - The bedside nurse asked the covering physician if the peripheral IV could be extended for an additional … prevent peripheral IV complications is through the use of IV therapy teams IV therapy teams include registered … nurses specially trained for inserting IV catheters and inspecting catheter sites IV teams can significantly

9803. Alternatives to potentially inappropriate medications for use in e-prescribing software: triggers and treatment algorithms. | PSNet
      psnet.ahrq.gov/issue/alternatives-potentially-inappropriate-medications-use-e-prescribing-software-triggers-and
      February 18, 2011 - December 5, 2012 Nurses' and nursing assistants' perceptions of patient safety culture

9804. New 2011 survey of patients with complex care needs in eleven countries finds that care is often poorly coordinated. | PSNet
      psnet.ahrq.gov/issue/new-2011-survey-patients-complex-care-needs-eleven-countries-finds-care-often-poorly
      February 22, 2010 - Electronic communication of medication information between nurses in home health care and general practitioners

9805. Puh-Erepguide (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-erepguide.docx
      February 10, 2014 - Ulcer Assessment was developed by a multistate multidisciplinary design team that consisted of wound nurses … , nurse leaders, and consultants from standalone nursing homes, large nursing home chains, and wound … Epithelialization Ulcer pain Current stage Followup ulcer status (improving, no change, worsening) per nurse … The wound nurse, wound physician, and other disciplines attending wound rounds can see quickly which … The Pressure Ulcer Counts by Month Report compiles pressure ulcer data captured by nurses on the weekly

9806. AHRQ’s Safety Program for Nursing Homes: On-Time Facilitator Training | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/impguide.html
      July 01, 2017 - Champion (Quality Assessment and Assurance [QAA] Coordinator) [Beth] Director of Nursing (DON) [Mary] Nurse … Manager Unit A [Jill] Nurse Manager Unit B [Frank] Minimum Data Set (MDS) Coordinator [Caroline]

9807. | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/studies/index.html
      January 01, 2025 - through observation, shadowing, and interviews, along with surveys at the patient-shift level from nurses … Keywords: Primary Care, Patient-Centered Healthcare McMenamin A , Turi E , Liu J Nurse … This study examined the effect of nurse practitioners (NPs) care environments on the relationship between … Nurse practitioner care environments and provider shortages among patients with multiple chronic conditions

9808. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery | PSNet
      psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
      March 25, 2020 - The surgeon took the internal paddles and requested the circulating nurse to get ready for synchronized … The nurse acknowledged and the patient was shocked at 10 Joules. … number of pieces of equipment in the room, the defibrillator screen was visible only to the circulating nurse … familiar with the location and the operation of the defibrillator Anesthesia clinicians and circulating nurses

9809. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838221/psn-pdf
      September 28, 2022 - In a scaled-up model, I do think that having a physician medical director and a nurse or [someone at … the] nurse practitioner level to supervise large numbers of community health workers is the other important … would assist with linkage to care, CNAs would get the patient’s medical history and vital signs, and nurses … community health workers and an MPH-level population health expert, as well as healthcare providers, nurse

9810. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865429/psn-pdf
      April 24, 2024 - The surgeon took the internal paddles and requested the circulating nurse to get ready for synchronized … The nurse acknowledged and the patient was shocked at 10 Joules. … number of pieces of equipment in the room, the defibrillator screen was visible only to the circulating nurse … familiar with the location and the operation of the defibrillator Anesthesia clinicians and circulating nurses

9811. Implement Teamwork and Communication for Perinatal Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/implement/implement-facilitator-guide.pdf
      May 01, 2017 - to meet family member needs, • Improved patient experience with care scores, and • Lower rates of nurse … Executives, obstetricians, nurse managers, pediatric providers, pharmacists, anesthesiology providers … , midwives, nurses, and L&D unit support staff approach issues in distinct ways, and shadowing provides … Example: The nurse says to the doctor, “Doctor, the patient’s blood pressure is dropping; it is 60

9812. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression | PSNet
      psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
      May 26, 2021 - opioid-induced respiratory depression, deaths most frequently occur overnight between 00:00-06:00 am when nurse … 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 … See More About The Topic Hospitals Intensive Care Units Operating Room Physicians Nurses

9813. In Conversation With… J. Bryan Sexton, PhD, MA | PSNet
      psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma
      February 26, 2025 - Linda Aiken has shown that about 34% of nurses meet the criteria for severe emotional exhaustion or … big face-to-face meeting with all the executives, the sponsors of the units, physician champions, the nurse … in the hallway getting a cup of coffee between some of the sessions, I was literally attacked by a nurse … I'll go back to that hallway interaction with that nurse as something that really changed the course

9814. 124-Cusp-Science-Safety-Fg (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/124-cusp-science-safety-fg.docx
      April 01, 2025 - One example is requiring a nurse or provider to repeat back a critical action laboratory value or verbal … The emergency department (ED) nurse collected Marta’s medical history, which included hormone replacement … The nurse shared Marta’s medical history with the ED attending physician, but failed to record that the … A team of just physicians or just nurses won’t lead to the change efforts needed.

9815. Vial Mistakes Involving Heparin | PSNet
      psnet.ahrq.gov/web-mm/vial-mistakes-involving-heparin
      May 11, 2014 - At Methodist Hospital (Indianapolis) in 2006, three infants died and three were injured when nurses … omitted second manual check or bar code scan before dispensing, confirmation bias on the part of nurses … Failure of nurses to recognize concentration differences can lead to serious errors when dosages are … Then upon transfer of the patient from the OR with the continuous infusion, the nurses may reprogram … Drug recognition by nurses and anaesthetists. Anaesthesia. 1982;37:206-208. [go to PubMed] 5.

9816. 5 Tk2 P3T2-Sample Procedures Phase 3 (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P3T2-Sample_Procedures_Phase_3.doc
      January 01, 1999 - Initial and ongoing training for nurses 3.

9817. Facilitator Guide: Learning From Defects Through Sensemaking (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
      December 01, 2017 - registered nurse anesthetists, surgeons, and environmental services personnel). … Due to the busy emergency room, the triage nurse does not notice that her cane was left behind. 3. … On the way out of the ICU, the nurse handed over the chart with the Kardex stamp plate. … In fact, he was also the relative of one of the ICU nurses. … We’re nurses. We’re doctors. We’re highly educated, and sometimes feel insulted by the tools.

9818. Learning from Primary Care EHR Exemplars About HIT Safety - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r21hs024327-ornstein-final-report-2018.pdf
      January 01, 2018 - “We found out if we give nurses something to do, they work off checklists and you get better care.” … A third assigned this responsibility to a trusted registered nurse, particularly for well child care … “Tracking is easy and that’s lovely but human beings still need to be involved…my nurses go through … Some have hired nurses to conduct this work or designate a specific nurse to do so. … physician, registered nurse) or group of clinicians should curate clinical updates and modify

9819. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33704/psn-pdf
      December 01, 2010 - I was listening to the patient, and I was listening to the doctors and nurses. … How about among caregivers, particularly doctors and nurses? … The nurses and staff there talked to me. They answered my questions. … Remember I'm not a nurse, I'm a PhD counselor. … And it would be a question such as, "A nurse came in asking for consent for a test, but nobody had talked

9820. Rapid response systems and collective (in)competence: an exploratory analysis of intraprofessional and interprofessional activation factors. | PSNet
      psnet.ahrq.gov/issue/rapid-response-systems-and-collective-incompetence-exploratory-analysis-intraprofessional-and
      June 19, 2012 - This qualitative study of physicians and nurses at an Australian hospital found that an impaired culture … 25, 2016 Factors affecting attitudes and barriers to a medical emergency team among nurses … January 19, 2014 Nurses' attitudes to a medical emergency team service in a teaching … , 2011 View More See More About The Topic Hospitals Physicians Nurses