-
psnet.ahrq.gov/issue/measuring-overall-development-patient-safety-new-hospital-using-trigger-tools
April 12, 2019 - 6 months, highlighting the importance of proactive identification of unsafe situations and close monitoring … Delayed recognition of deterioration of patients in general wards is mostly caused by human related monitoring … incidence of cardiorespiratory instability in patients in step-down units using an electronic integrated monitoring
-
psnet.ahrq.gov/issue/operational-failures-general-practice-consensus-building-study-priorities-improvement
February 07, 2024 - Related Resources From the Same Author(s)
Why is safety in intrapartum electronic fetal monitoring … May 13, 2020
Effectiveness and safety of pulse oximetry in remote patient monitoring … August 3, 2022
Impact of non-interruptive medication laboratory monitoring alerts in
-
psnet.ahrq.gov/node/35104/psn-pdf
April 06, 2011 - Using the first 4000 reports from the Australian Incident Monitoring Study (AIMS), a team of
anesthetists
-
psnet.ahrq.gov/node/49749/psn-pdf
December 01, 2015 - attending saw the patient and decided to transfer him to the intensive care unit (ICU) for closer
monitoring … Maintaining the continuous insulin and
dextrose infusions in this situation would have been a better … approach, allowing for closer monitoring and
titration of insulin dosing even while the patient was … of protocols to transition
from IV to subcutaneous insulin
Tasks
High workload and time pressure
situation … management
Attending physician oversight of
plan of care upon ICU transfer
Organizational performance
monitoring
-
psnet.ahrq.gov/web-mm/elopement
July 14, 2010 - Finding that a patient has "gone missing" is a scary situation for providers and patients' families. … without informing staff, response to their absence is based on what is reasonable for the particular situation … policies and procedures in place indicating the steps that personnel are to follow in any elopement situation … Such a protocol may include locating the patient close to the desk, placing an electronic monitoring … In one ED, the use of the RF devices and a new triage protocol reduced the need for one-to-one monitoring
-
psnet.ahrq.gov/node/49664/psn-pdf
January 01, 2013 - The electronic health record (EHR) did not reflect the glucose levels because the bedside
glucose-monitoring … Perhaps
the most ubiquitous attempt to standardize handoffs has been the SBAR (situation, background … roles
Task allocation
All members have
dedicated
tasks:
-
Ventilation: anesthetists
-
Monitoring … by most able
team member ("lollipop
man"), who notices,
understands, and predicts
consequences
Situation … awareness
Consultants maintain overall
picture and awareness by
standing back and monitoring
rather
-
psnet.ahrq.gov/web-mm/danger-disruption
July 29, 2020 - The nurse informed them that hospital policy prohibited sedation in the unit without monitoring. … In the meantime, propofol was administered without monitoring. … Upon her return, the nurse observed that the child was apneic and again requested monitoring. … The situation was "saved" by the patient's nurse, who in the midst of a very difficult encounter with … Monitoring for continued abuse of people and policies is the responsibility of physician and nurse leaders
-
psnet.ahrq.gov/issue/world-health-organization-world-federation-societies-anaesthesiologists-who-wfsa
November 16, 2015 - related to professional qualification; facilities and equipment ; medications and intravenous fluids; monitoring … October 10, 2012
Recommended guidelines for monitoring, reporting, and conducting research … Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring
-
psnet.ahrq.gov/node/42300/psn-pdf
May 29, 2013 - effect-noise-auditory-processing-operating-room
https://psnet.ahrq.gov/issue/ergonomic-and-human-factors-affecting-anesthetic-vigilance-and-monitoring-performance
-
psnet.ahrq.gov/perspective/reducing-safety-hazards-monitor-alert-and-alarm-fatigue
May 01, 2016 - some alarms are truly appropriate, and silencing them indiscriminately can lead to a life-threatening situation … Physiologic monitoring alarm load on medical/surgical floors of a community hospital. … and then a new nurse—it's when hospital monitoring began. … BD : I have been in this cardiac monitoring business for over 40 years. … problems, and knows that in the last 1000 cases an alarm has fired in this type of patient—in this situation
-
psnet.ahrq.gov/issue/2008-recommendations-pre-anesthesia-checkout-procedures
April 22, 2020 - , 2021
Root cause analysis using the prevention and recovery information system for monitoring … August 9, 2023
APSF endorsed statement on revising recommendations for patient monitoring
-
psnet.ahrq.gov/periodic-issue/periodic-issue-415
November 29, 2023 - Study
Use of design thinking and human factors approach to improve situation awareness … Shared situation awareness is shown to improve patient outcomes in the pediatric intensive care unit … With the new tools in place in the new PICU, shared situation awareness for residents, nurses, and respiratory … Quantitative blockade monitoring revealed a “train of four” (TOF) ratio less than 70%, so she was given
-
psnet.ahrq.gov/issue/awareness-and-use-cognitive-aid-anesthesiology
January 05, 2017 - August 21, 2019
Customer focused incident monitoring in anaesthesia.
-
psnet.ahrq.gov/node/33586/psn-pdf
September 07, 2019 - they computerized provider order entry systems (CPOE), smart
intravenous infusion pumps, or cardiac monitoring … deaths over a 5-year period attributable to failure to appropriately heed alarms
from physiologic monitoring
-
psnet.ahrq.gov/issue/improving-patient-safety-human-factors-methods
June 12, 2019 - Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring
April 26, 2023 … Perspective
Surveillance Monitoring to Improve Patient Safety
-
psnet.ahrq.gov/node/49532/psn-pdf
March 15, 2007 - wrong" rule-based errors—the rule is strong in general but was inappropriate
or misapplied in this situation … of insulin requirements and institution of a
variable-rate insulin infusion with frequent glucose monitoring … Implementing these algorithms requires adequate training and
supervision of staff and close monitoring … Information technology (e.g., EHR and CPOE) can serve as a useful tool to improve monitoring and
ordering
-
psnet.ahrq.gov/web-mm/dangerous-shift
July 24, 2013 - traded off against the potential benefits of the additional care provided by ICU nurses and specialized monitoring … most policies currently recommend a "blanket" approach to standardization of content or format (e.g., Situation-Background-Assessment-Recommendation … as by grouping patients under the care of a particular provider in one place and enabling peripheral monitoring … Local actors must tailor a distant supervisor's plan to the situation. … ambulatory care safety: a novel method to develop context-sensitive interventions to reduce quality gaps in monitoring
-
psnet.ahrq.gov/perspective/conversation-barbara-drew-rn-phd
May 01, 2016 - and then a new nurse—it's when hospital monitoring began. … BD : I have been in this cardiac monitoring business for over 40 years. … problems, and knows that in the last 1000 cases an alarm has fired in this type of patient—in this situation … some alarms are truly appropriate, and silencing them indiscriminately can lead to a life-threatening situation … Physiologic monitoring alarm load on medical/surgical floors of a community hospital.
-
psnet.ahrq.gov/web-mm/chest-tube-complications
September 27, 2023 - ventilation, which increases the likelihood and risk of an air leak).( 11 ) During a clamp trial, close monitoring … this case include lack of clear guidelines on chest tube removal, such as assigning responsibility for monitoring … chest tube care path that outlines an algorithm for safe removal of chest tubes, including frequency of monitoring … September 25, 2019
Improving situation awareness to advance patient outcomes: a systematic
-
psnet.ahrq.gov/web-mm/empty-handoff
August 01, 2017 - The electronic health record (EHR) did not reflect the glucose levels because the bedside glucose-monitoring … Perhaps the most ubiquitous attempt to standardize handoffs has been the SBAR (situation, background, … All members have dedicated
tasks:
-
Ventilation: anesthetists
-
Monitoring … capture by most able team member ("lollipop man"), who notices, understands, and predicts consequences
Situation … awareness
Consultants maintain overall picture and awareness by standing back and monitoring rather