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121. Do Transient Working Conditions Trigger Medical Errors? (pdf file)
     ce.effectivehealthcare.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.

122. AHRQ Grant Final Progress Report: Improving Patient Safety Through Provider Communication Strategy Enhancements (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-01/daugherty-report.pdf
     January 01, 2024 - On the nursing units, huddles typically were led by the nurse manager, charge nurse, or clinical nurse … , the individual patient’s nurse, and a pastoral care provider. … Collaboration between nurses and physician: no longer a choice. Acad Med 1997; 5:295-303. 9. … She won’t be dancing anyway: a study of surgeons, surgical nurses, and elder patients. … Nurses and doctors: a problem of partnership. In: Soothill K, Mackay L, Web C, editors.

123. Experiences From the Frontline: Case Studies (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/frontline-cases-studies.pdf
     May 01, 2015 - champion, staff nurses, the L&D nurse manager, QI coordinators, an obstetrician/gynecologist physician … care teams—the obstetrics and gynecology providers, the in-house anesthesiologists, the certified registered … nurse anesthetists (CRNAs), and the L&D nurses. … The rapid response nurse then alerts the charge nurse in the operating room. … Training all unit nurses first.

124. The Role of the Nurse Manager | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/cusp/videos/09a-role-nurse-manager/index.html
     June 01, 2018 - Decolonization – Universal and Targeted Tools The Role of the Nurse … toolkit includes training tools to make care safer by improving the foundation of how your physicians, nurses … The Role of the Nurse Manager [10 min. 14 sec.] … June 2018 Page originally created February 2013 Internet Citation: The Role of the Nurse … https://www.ahrq.gov/hai/cusp/videos/09a-role-nurse-manager/index.html  

125. Strategy 2: Communicating for Improve Quality (Tool 1) (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy2/Strat2_Tool_1_Be_Partner_508.pdf
     May 24, 2013 - 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.].

126. TeamSTEPPS Speciality Scenarios, Labor & Delivery (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/labordel.pdf
     March 18, 2014 - She calls the registered nurse (RN) team leader seeking help. … After evaluating Amy, her primary nurse (registered nurse [RN]) discusses the plan of care with the … The Triage nurse seeks out the registered nurse (RN) team leader in L&D, who is occupied with an active … A prolonged deceleration occurs, and the registered nurse (RN) calls in a resident. … He asks the registered nurse (RN) to provide fundal pressure.

127. Strategy 2: Communicating for Improve Quality (Tool 1) (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy2/Strat2_Tool_1_Be_Partner_508.docx
     February 10, 2011 - Engagement 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 … Your nurses will change shifts between [7 and 7:30 a.m.] and [7 and 7:30 p.m.].

128. CAHPS Child Hospital Survey Measures | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/cahps/surveys-guidance/hp/about/child-survey-measures.html
     June 01, 2017 - Q14 Nurses listened carefully to parent Q15 Nurses explained things to parent in a way that was … easy to understand Q16 Nurses treated parent with courtesy and respect Communication Between You … Q25 Providers gave parent enough information about test results Privacy When Talking With Doctors, Nurses … Communicate With Your Child Q8  Nurses listened carefully to child Q9  Nurses explained things to … child in a way that was easy to understand Q10 Nurses encouraged child to ask questions How Well

129. Getting Ready (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/getting_ready.pdf
     May 01, 2017 - The care team also includes the doctors, nurses, and other health care professionals who help take care … Operating room nurse or circulating nurse: a registered nurse who is in the surgery/procedure room to … The members of the anesthesia team vary and might include nurses, anesthesiologists, and certified registered … nurse anesthetists (CRNAs). … Recovery room or post-anesthesia care unit (PACU) nurse: a nurse who monitors you immediately after surgery

130. Strategy 2: Communicating to Improve Quality (Tool 3) (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/asc-checklist-template.docx
     January 01, 2009 - Ambulatory Surgery Implementation Guide Ambulatory Surgery Checklist Preop Before Patient Enters Room Nurse … performing the procedure · Patient position · Known allergies · Patient weight · History and physical Nurse … Surgeon, Nurse, and Anesthesia Professional perform the Timeout · Patient’s name · Surgical procedure … and Scrub Tech Share: · Equipment issues · Other concerns Circulating Nurse and Scrub Tech Confirm: … Before Patient Leaves Room/Debriefing Nurse Reviews With Team: · Instrument, sponge and needle counts

131. Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harder.pdf
     May 19, 2003 - • Nurse educators responsible for training nursing staff on the use of the drug. … Temporary assignment of nurses. … Instruction of temporarily assigned nurses When a nurse is on temporary assignment, the nurse in charge … to staff nurses and pharmacists. … by the nurse in charge of that station, who should inform the temporarily assigned nurse how computers

132. Section 5. Preparing to Launch | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/findings/final-reports/ptflow/section5.html
     July 01, 2018 - For example, nurses spent a lot of time searching for equipment and supplies. … ED nurse managers, charge nurses, and staff nurses spent more time planning and implementing strategies … An additional 160 hours (4 hours each for 40 nurses) were spent on the initial training of staff nurses … The team consisted of three physicians, two nurses, two nurse practitioners, a technician, a registration … Also, two nurses attended a train-the-trainer triage course ($16,850). Large expenditures.

133. Prompting Removal of Unnecessary Indwelling Urinary Catheters Facilitator Notes (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-removal-notes.docx
     April 01, 2022 - criteria, meaning that they are empowered, and the culture supports that empowerment. · Daily review by nurses … We highly recommend nurse-driven protocols that empower nurses to remove unnecessary urinary catheters … Use of surgical safety checklists is endorsed by AORN, the Association of Perioperative Registered Nurses … When the nurse-driven protocol is present, consider strategies to empower nurses to remove the urinary … The level of respect among nurses and physicians can also impact whether physicians are receptive to

134. Strategy 4: IDEA Discharge Planning (Implementation Handbook) (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Implement_Hndbook_508_v2.docx
     April 01, 2011 - about steps toward discharge Bedside nurse Daily activities Blank cell. … identify needs and adapt the strategy; the trainers to prepare and conduct the training; staff champions (registered … Periodically monitoring nurses gave nurses helpful and timely feedback. … Then, nurse leaders held a 6-hour training session for selected nurses, including members of the unit-based … council and nurses who were working towards promotion.

135. CAHPS Nursing Home Survey: Family Member Instrument (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/nh/nursing-home-family-eng-1652a.doc
     September 01, 2011 - In the last 6 months, during any of your visits, did you try to find a nurse or aide for any reason? … In the last 6 months, how often were you able to find a nurse or aide when you wanted one? … Was it because the nurses or aides either didn’t help or made him or her wait too long? … Was it because the nurses or aides either didn’t help or made him or her wait too long? … In the last 6 months, did you want to get information about your family member from a nurse or an aide

136. The Emergency Department & Catheter Insertions | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/cauti-tools/archived-webinars/ed-catheter-insertions-slides.html
     December 01, 2017 - Physician and nurse practice influences this relationship greatly. … Engage nurses ( significant role in UC use). Engage physicians ( significant role in UC use). … Nurses? Physicians? Hospitalists? Intensivists? Patients? … Saves time for the bedside nurse. … Both physicians and nurses need to model ethically-driven, patient focused, collaborative care.

137. Exhibit 9. Strategies to Engage Patients and Families as Part of the Health Care Team | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamilyex9.html
     July 01, 2018 - Improved staff satisfaction. 2,3 Length of stay decreased. 166 Bedside change of shift 172-174 Nurses … conduct bedside report for change of shift Patients, families, incoming/ outgoing nurses Nurses … Team response includes nursing supervisor; others such as physician, unit nurse, or patient relations … given VIP button for family member/ friend and is considered part of care team 177 Family, patient, nurses

138. Observing Nurse Interaction with Infusion Pump Technologies (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Carayon.pdf
     January 01, 2004 - Observing Nurse Interaction with Infusion Pump Technologies 349 Observing Nurse Interaction with … Information about the work environment, interruptions in the process, patient and nurse comments, nurse … Nurses responded to the interview questions with relative ease. … If the nurse consented, we then observed the nurse access the patient medication profile, take the medication … Patient names, nurse names, and any other information or data that could be used to identify the nurse

139. Engaging-Nurse-Physician-Patient-Transcript (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/engaging-nurse-physician-patient-transcript.docx
     September 25, 2015 - The nurse in the OR gave her port to the nurse in the ICU. … I'm the clinical nurse leader at Tucson Medical Center in the ICU. … What do we expect of these nurses? Making very clear goals. … The expectations being in your huddles you’re talking about it, your bedside report nurse-to-nurse, you're … I can tell you my champion, nurse champions at night, were great.

140. Communication-Material-Guide (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/communication-material-guide.docx
     May 01, 2017 - Materials: Slides 12-25, Example Briefing and Debriefing videos Audience: Surgeons, anesthesia, scrub nurses … , circulating nurses, nurse manager Topic: The Surgical Checklist as a Communication and Teamwork Tool … Materials: Slides 26-32, examples of checklists Audience: Administration, surgeons, anesthesia, all nurses … Materials: Slides 33-41, examples of checklists Audience: Administration, surgeons, all nurses AHRQ … Slides 33-41, Tabletop Simulation video, checklist Audience: Administration, surgeons, anesthesia, all nurses