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psnet.ahrq.gov/issue/promethazine-adverse-events-after-implementation-medication-shortage-interchange
October 26, 2010 - number of prescribed medications a patient is currently receiving can affect his or her safety in this situation
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psnet.ahrq.gov/issue/promoting-civility-or-ethical-imperative
September 12, 2016 - interactions can influence the safety of care delivery and highlights ways nurses can mitigate the situation
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psnet.ahrq.gov/node/847539/psn-pdf
April 12, 2023 - Potential uses of AI for perioperative nursing handoffs: a
qualitative study.
April 12, 2023
King CR, Shambe A, Abraham J. Potential uses of AI for perioperative nursing handoffs: a qualitative
study. JAMIA Open. 2023;6(1):ooaf015. doi:10.1093/jamiaopen/ooad015.
https://psnet.ahrq.gov/issue/potential-uses-ai-perio…
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psnet.ahrq.gov/issue/acting-wisely-complex-clinical-situations-mutual-safety-clinicians-well-patients
June 16, 2021 - Study
Acting wisely in complex clinical situations: 'Mutual safety' for clinicians as well as patients.
Citation Text:
Dornan T, Lee C, Findlay-White F, et al. Acting wisely in complex clinical situations: ‘Mutual safety’ for clinicians as well as patients. Med Teach. 2021;43(12):1419-14…
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psnet.ahrq.gov/node/47587/psn-pdf
February 13, 2019 - Comfort with uncertainty: reframing our conceptions of
how clinicians navigate complex clinical situations.
February 13, 2019
Ilgen JS, Eva KW, de Bruin A, et al. Comfort with uncertainty: reframing our conceptions of how clinicians
navigate complex clinical situations. Adv Health Sci Edu: Theory Pract. 2019;24(4):…
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psnet.ahrq.gov/node/49520/psn-pdf
September 01, 2006 - interventions and even reduce the level of anesthesia and analgesia to ensure stable vital functions; either
situation … physician’s attention, she can make an
individualized decision, taking into account the patient’s clinical situation
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psnet.ahrq.gov/issue/action-needed-prevent-dangerous-heparin-insulin-confusion
May 07, 2018 - Citation
Related Resources From the Same Author(s)
Remote CPOE error—a situation
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psnet.ahrq.gov/node/836811/psn-pdf
April 07, 2022 - Implementing a watcher program to improve timeliness of
recognition of deterioration in hospitalized children
April 7, 2022
Evans S, Green A, Roberson A, et al. Implementing a watcher program to improve timeliness of
recognition of deterioration in hospitalized children. J Pediatr Nurs. 2021;61:151-6.
https:/…
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psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status
March 27, 2024 - temporarily changed her code status to "full code," completed the procedure, and then discussed the situation … Yet, these are life-and-death matters that must be discussed promptly, especially with a situation like … In a situation where a patient would not want aggressive or invasive interventions, failure to enter … But there was certainly the potential to harm a patient in this situation by not respecting her wishes … training to the nuances of specific treatment preferences would have probably helped avoid this near-miss situation
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psnet.ahrq.gov/issue/apsf-20-year-anniversary-first-patient-safety-organization-past-present-future
October 26, 2022 - March 10, 2021
Three quarters of preventable patient harm stems from situation awareness
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psnet.ahrq.gov/issue/lean-six-sigma-reduces-medication-errors
January 18, 2023 - February 2, 2020
Clinical progress note: situation awareness for clinical deterioration
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psnet.ahrq.gov/issue/patient-safety-and-quality
January 19, 2022 - November 25, 2009
Supporting structures for team situation awareness and decision making
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psnet.ahrq.gov/issue/five-year-audit-adherence-anaesthesia-pre-induction-checklist
May 19, 2021 - Beyond the surgical safety checklist: using intraoperative handoff to facilitate team situation
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psnet.ahrq.gov/issue/effects-brief-team-training-program-surgical-teams-nontechnical-skills-interrupted-time
December 08, 2021 - June 8, 2011
Discrepant perceptions of communication, teamwork and situation awareness
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psnet.ahrq.gov/issue/healthcare-utilizing-deliberate-discussion-linking-events-huddle-systematic-review
November 16, 2022 - July 25, 2024
- July 25, 2024
Teamwork matters: team situation awareness to build
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.127_slideshow.ppt
May 01, 2006 - layer of defense has weaknesses
Adverse events occur only when all the defenses around a particular situation … While some might call this case a "near miss" or close call—a situation that could have led to an adverse … Near Miss – An event or situation that did not produce patient injury, but only because of chance.
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psnet.ahrq.gov/node/33687/psn-pdf
August 01, 2009 - the ability to improvise with materials at hand to fashion a solution to an
unexpected problem or situation … tasks without interrupting other harried staff who might
otherwise be called upon to help rectify the situation … However, they would take the initiative to verbally mention the
situation to a manager or physician
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psnet.ahrq.gov/issue/measuring-teamwork-performance-teams-crisis-situations-systematic-review-assessment-tools-and
November 04, 2020 - Review
Emerging Classic
Measuring the teamwork performance of teams in crisis situations: a systematic review of assessment tools and their measurement properties.
Citation Text:
Boet S, Etherington N, Larrigan S, et al. Measuring the teamwork performance of tea…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.209_slideshow.ppt
December 01, 2009 - In efforts to make the best of the situation, physicians caring for the patient elected to discharge … Ability to communicate a choice
Ability to understand relevant information
Ability to appreciate the situation
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psnet.ahrq.gov/issue/management-changing-errors-recall-radiologic-results-pilot-study
February 18, 2011 - Incorrect understanding of radiology reports by treating clinicians occurred frequently in this study, a situation