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121. Making Healthcare Safer Practices: 14. Delirium (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/delirium-1.pdf
     March 01, 2020 - Crit Care Nurse. 2018;38(1):38-49. doi: 10.4037/ccn2018633. 14. … Clin Nurse Spec. 2011;25(6):299-311. doi: 10.1097/NUR.0b013e318234897b. 27. … A preoperative, nurse-led intervention program reduces acute postoperative delirium. … screening tools to detect delirium in patients with neuroscience diagnoses Pre-post design; 47 registered … Moderate LaFever et al., 201516 Delirium education program to increase oncology registered nurses

122. Final Progress Report: Changes in Hospital Care Organization and Outcomes (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/kutney-lee-report.pdf
     January 01, 2024 - In both 1998-1999 and 2006, nurses completed a self-administered paper survey mailed to their homes … A single item on the nurse survey that asked about the degree to which nurses were satisfied with their … Nurses were asked to report the number of patients cared for on their last shift on the survey. … Nurse education. On the survey, nurses were asked to report the highest degree earned in nursing. … nurses’ responses for each subscale. 5 Then, hospital nurse practice environments were categorized

123. Falls Prevention Self-Assessment Worksheet - AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallspxselfassessment.pdf
     June 02, 2025 - )  Admitting Nurse  Charge Nurse  Nurse Manager  Nursing Supervisor  Director of Nursing …  MDS Nurse  Charge Nurse  Nurse Manager  Nursing Supervisor  Director of Nursing  Physical …  Charge Nurse  Nurse Manager  Nursing Supervisor  Director of Nursing  Physical Therapist … falls Nurses _____ Therapy _____ CNAs _____ Nurses _____ Therapy _____ CNAs _____ Effective … restorative/strengthening exercises Nurses _____ Therapy _____ CNAs _____ Nurses _____ Therapy _

124. The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Faltz_56.pdf
     March 27, 2008 - nurses, certified registered nurse anesthetists, OR clinical nurse specialists, nurses, hospital association … All of the Code 911 cases and 2 years of Code 912 cases were analyzed by at least one nurse and one … Nurses, and the American Association of Eye and Ear Hospitals; 2001. … Association of PeriOperative Registered Nurses (AORN) Statement on correct site surgery. … Denver, CO: Association of PeriOperative Registered Nurses; 2005.

125. Final Progress Report: Using Barcode Technology to Improve Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/gandhi-report.pdf
     January 01, 2024 - Seger, PharmD, Co-Investigator Mary Ann Lunn, RN, Research Nurse Sharon Gard, RN, Research Nurse Heather … Hogan, RN, Research Nurse Virginia Davis, RN, Research Nurse Kathleen Bell, RN, Research Nurse Erica … Information was also collected regarding the gender, age, and years post training of each nurse. … findings can help allay concerns regarding the impact of BCMA on nursing workflow and quantity of direct nurse-patient … The Medication Administration System-- Nurses Assessment of Satisfaction (MAS-NAS) scale.

126. The Emergency Department & Catheter Insertions | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/ed-catheter-insertions-slides.html
     December 01, 2017 - John Hospital and Medical Center Lisa Wolf, PhD, RN, CEN, FAEN Emergency Nurses Association (ENA) … Physician and nurse practice influences this relationship greatly. … Engage nurses ( significant role in UC use). … Nurses? Physicians? Hospitalists? Intensivists? Patients? … Saves time for the bedside nurse.

127. Final Progress Report: Developing Definitions, Measurement Strategies, and Links to Medication Errors (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/savage-report.pdf
     January 01, 2024 - chose different types of facilities (an academic medical center, two community hospitals – one with Nurse … This finding highlights the important potential negative impact of perceived work flow barriers and nurse … Therefore, even if it were an improvement on the process, it was limited to just that one nurse (unless … We found a number of examples in which a workaround by a nurse led him or her to engage in additional … Response to Barriers, and Potential Impact on Patients (Nurse response coded W=Workaround, R=Rework

128. Final Progress Report: Improving the Safety of Primary Care by Measuring Adverse Events and Improvement (pdf file)
     www.ahrq.gov/sites/default/files/2024-03/kennerly-report.pdf
     January 01, 2024 - These five nurses were contractors with KDJ Consulting, an agency that has provided nurse chart reviewers … Charts were reviewed for AEs by external nurse auditors using the BI-OTT. … The experienced nurse answered the same question with “very effective.” … We relied on the input of nurses and experienced nurse auditors to develop and refine the toolkit. … of nurses across the United States to determine training preferences, we feel that these nurses gave

129. Do Transient Working Conditions Trigger Medical Errors? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Grayson.pdf
     January 01, 2003 - Nursing personnel directly involved in a medical error were interviewed within 2 weeks of the error. … Methods Subjects were nursing personnel (registered nurses, patient care technicians, licensed practical … The majority of participants were registered nurses (84 percent), with 63 percent of them usually working … Given the nature of this study, we anticipated that nursing personnel might be reluctant to discuss … Surprisingly, we discovered that nursing personnel wanted to talk about their errors.

130. Final Progress Report: The ED Pharmacist as a Safety Measure in Emergency Medicine (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/fairbanks-report.pdf
     January 01, 2024 - Exclusions During the nurse abstraction process, six exclusion criteria were identified. … Nurses include all Registered Nurses and Licensed Practical Nurses. … Nurses n=42 No (%; 95% C.I.) … Nurse and doctor perceptions reinforce the value of clinical pharmacists in the ED. … Exclusions During the nurse abstraction process, six exclusion criteria were identified.

131. Arriving Home Safely Infographic | Agency for Healthcare Research and Quality
     www.ahrq.gov/nursing-home/resources/arriving-home-safely.html
     June 01, 2022 - Home Safely Infographic Resource: Arriving Home Safely Infographic This infographic for nurses … Source: ANA - American Nurses Association Topic(s): Staff and Resident Well-being; Infection Prevention

132. Final Progress Report: Emotional Influences on Diagnostic Error in Emergency Medicine: An Experimental Approach to Understand Diagnostic Failure and Facilitate Improvement for Patients with and without Mental Illness (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/isbell-boudreaux-report.pdf
     January 01, 2025 - procedures to confirm that everyone who requested a link to participate was an emergency physician or nurse … Contacts (e.g., nurse managers) at eight hospitals shared our study invitation with emergency nurses … An expert nurse and researcher on our team (Gleason) adapted the cases for nurses. … in which participants wrote up the information they would provide in a verbal report for the next nurse … Our nurse expert coded test recommendations to capture whether participants recommended at least one

133. Final Progress Report: Pediatric patient safety learning laboratory to re-engineer continuous physiologic monitoring systems (pdf file)
     www.ahrq.gov/sites/default/files/2024-05/bonafide-report.pdf
     January 01, 2024 - ECRI engineers investigated nurse workflow and alarm effectiveness. … Relationship of alarm exposure to nurse workload: We analyzed the relationship between alarms and nurse … Nurse questionnaire We administered an in-person questionnaire to 98 bedside nurses, inquiring about … (e.g., leadership nurses, a nurse holding the primary nurses' phone). … Observed team-based behaviors included nurses checking on each other, nurses checking on other nurses

134. Strategy 2: Communicating for Improve Quality (Tool 1) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy2/Strat2_Tool_1_Be_Partner_508.pdf
     June 02, 2025 - We work as a team to make sure you get the best care Your health care team includes you, doctors, nurses … If you or your family needs to talk to a doctor at any time, please let your nurse know. … • Nurse shift changes occur when nurses who are going off duty share information about you with … nurses who are coming on duty. … Your nurses will change shifts between [7 and 7:30 a.m.] and [7 and 7:30 p.m.].

135. Nursing Intervention to Remove Non-necessary Urinary Catheters
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/building-team-040814.pptx
     January 01, 2013 - Has good rapport with the medical staff Preferably from that unit: nurse manager, charge nurse, nurse … educator, or frontline nurse Optional, but less desirable: nurse from organization at large: quality … communicate the technical work/changes needed to stakeholders (nurses and physicians)? … Manager (or charge nurse) Case Manager (or discharge planner) Social Worker Bedside nurses assigned … The nurse champion discusses with each nurse on the unit the presence and need of the catheter Alternatively

136. Final Progress Report: An Evaluation of the Effectiveness and Process Evaluation of a Rapid Response System (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/lord-report.pdf
     January 01, 2024 - A study from Australia with a sample size of 73 nurses found that, the more experienced the nurse, … were more likely to consult with a more experienced nurse before calling the RRT, even when this was … and staff performance: Nurse and RRT member performance Are the RRS protocols being followed? … tend to ask the more experienced nurses before calling themselves Concerns from the Bedside Nurses … are being taught by the responding team • Other nurses will take over the patients of a nurse who has

137. About the Toolkit Development | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/ambulatory-surgery/about.html
     May 01, 2017 - Participating organizations American Academy of Orthopaedic Surgeons American Association of Nurse … Association of periOperative Registered Nurses International Association of Healthcare Central Service

138. Building a Team and Process to Reduce CAUTI Risk | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/building-team-process-slides.html
     December 01, 2017 - Has good rapport with the medical staff Preferably from that unit: nurse manager, charge nurse, … nurse educator, or frontline nurse Optional, but less desirable: nurse from organization at large: … Manager (or charge nurse) Case Manager (or discharge planner) Social Worker Bedside nurses assigned … Nurse caring for patient 78/227 (34.4)    Case manager 4/227 (1.8)    Nurse caring for … patient and case manager 1/227 (0.4)    Nurse caring for patient, case managger, and nurse manager

139. Chapter 5. Education and Training | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/match/chapter-5.html
     July 01, 2022 - section contains information on effective strategies, materials, and tools for educating physicians, nurses … Education and Training Strategy Multidisciplinary training (i.e., physicians, nurses, and pharmacists … I'm your nurse, Katherine Johnson. Dr. … The "Questions to Ask During a Medication History" template was used by one provider as nurse prompts … and questions were put on a card, laminated, and added to the nurse ID lanyard.

140. Chapter 5. Education and Training | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/match/chapter-5.html
     July 01, 2022 - section contains information on effective strategies, materials, and tools for educating physicians, nurses … Education and Training Strategy Multidisciplinary training (i.e., physicians, nurses, and pharmacists … I'm your nurse, Katherine Johnson. Dr. … The "Questions to Ask During a Medication History" template was used by one provider as nurse prompts … and questions were put on a card, laminated, and added to the nurse ID lanyard.