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psnet.ahrq.gov/issue/scoping-review-distributed-cognition-acute-care-clinical-decision-making
April 08, 2020 - support alerts tailored to intensive care on the administration of high-risk drug combinations, and their monitoring … January 20, 2021
Patient monitoring alarms in the ICU and in the operating room.
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psnet.ahrq.gov/node/60268/psn-pdf
April 29, 2020 - balance between clotting in the ECMO circuit and bleeding in the patient is delicate and requires close
monitoring … should be commenced after a timeout, which includes a short introduction of the patient and the
current situation … A Situation-Background-Assessment-
Recommendation (SBAR) format is advisable for such briefings.10,11 … evaluated and the "Treatment A-B-C" may be the best tool for a structured
evaluation in a stressful situation … physician on the
other side of pump) keeps the same controlled distance but with eyes ahead and on the monitoring
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psnet.ahrq.gov/node/74252/psn-pdf
January 12, 2022 - There was an ongoing need for increased vigilance in patient monitoring.
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psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation
March 24, 2019 - In this clinical situation the capnograph is especially helpful because it can rule out esophageal intubation … Continuous monitoring of ventilation with a capnograph can diagnose this complication early, before the … An analysis of the reports submitted to the Australian Incident Monitoring Study in Intensive Care. … Capnography for Monitoring End-Tidal CO2 in Hospital and Pre-hospital Settings: A Health Technology Assessment
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psnet.ahrq.gov/web-mm/bloody-bp-cuff
June 21, 2016 - Blood contamination of anesthesia equipment and monitoring equipment.
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psnet.ahrq.gov/node/49398/psn-pdf
May 01, 2003 - Blood contamination of anesthesia equipment and monitoring equipment.
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psnet.ahrq.gov/node/33566/psn-pdf
September 07, 2019 - coupling teamwork
training programs with more specific efforts to structure communication, such as SBAR (situation
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psnet.ahrq.gov/issue/impacts-operational-failures-primary-care-physicians-work-critical-interpretive-synthesis
May 22, 2024 - August 28, 2024
Why is safety in intrapartum electronic fetal monitoring so hard? … December 1, 2021
A meta-review of methods of measuring and monitoring safety in primary
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psnet.ahrq.gov/periodic-issue/periodic-issue-428
February 28, 2024 - Newspaper/Magazine Article
Three quarters of preventable patient harm stems from situation … Situation awareness is a crisis management concept drawn from aviation safety to be used in examination … This article introduces situation awareness and how lack thereof can jeopardize patient safety. … The commentary highlights the importance of vigilant monitoring and good communication to identify and
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psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
March 15, 2023 - Describe how tracheostomy teams, staff education and cuff monitoring protocols help to avoid tracheostomy … This case highlights the importance of monitoring endotracheal and tracheostomy tube balloon pressures … until it is safe to perform the first tracheostomy tube change, but the team should acknowledge the situation … Policy and staff education should include airway cuff pressure monitoring technique and protocols. … Monitoring during mechanical ventilation.
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psnet.ahrq.gov/issue/evaluation-automated-surveillance-system-using-trigger-alerts-prevent-adverse-drug-events
August 30, 2017 - Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring
April 26, 2023 … Perspective
Surveillance Monitoring to Improve Patient Safety … December 21, 2018
Impact of non-interruptive medication laboratory monitoring alerts
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psnet.ahrq.gov/issue/ashp-guidelines-perioperative-pharmacy-services
December 21, 2014 - February 7, 2023
APSF endorsed statement on revising recommendations for patient monitoring
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psnet.ahrq.gov/issue/accuracy-global-trigger-tool-higher-identification-adverse-events-greater-harm-diagnostic
November 17, 2021 - Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring
April 26, 2023 … Perspective
Surveillance Monitoring to Improve Patient Safety
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psnet.ahrq.gov/issue/why-and-how-approach-user-experience-safety-critical-domains-example-health-care
May 05, 2021 - Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring
April 26, 2023 … Perspective
Surveillance Monitoring to Improve Patient Safety
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psnet.ahrq.gov/node/49565/psn-pdf
July 01, 2008 - The LPN's role should have been limited to monitoring the
nutrients over the course of the infusion. … In this situation, the bag and the tubing should have been clearly marked
for IV USE ONLY.
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psnet.ahrq.gov/node/849679/psn-pdf
June 28, 2023 - Describe how tracheostomy teams, staff education and cuff monitoring protocols help to avoid
tracheostomy … This case highlights the importance of
monitoring endotracheal and tracheostomy tube balloon pressures … until it is safe to perform the first tracheostomy tube change, but the team should acknowledge
the situation … Policy and staff education should include airway cuff pressure monitoring technique and protocols. … Monitoring during mechanical ventilation. Respir Care. 2020;65(6):832-846. [Free full
text]
16.
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psnet.ahrq.gov/issue/challenges-nurses-efforts-retrieving-documenting-and-communicating-patient-care-information
November 18, 2016 - Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring
April 26, 2023 … Perspective
Surveillance Monitoring to Improve Patient Safety
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psnet.ahrq.gov/node/49808/psn-pdf
October 01, 2017 - Consequently, the patient
received an excessive amount of the medication, which resulted in a near code situation … Patient monitoring needs should also be assessed. … for critical
care patients, that outline three phases: pretransfer coordination and communication, monitoring … Monitoring high-risk cardiac patients
during transportation in hospital. … An analysis of the reports submitted to the Australian Incident Monitoring
Study in Intensive Care.
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psnet.ahrq.gov/issue/machine-learning-evaluation-inequities-and-disparities-associated-nurse-sensitive-indicator
July 19, 2023 - June 19, 2024
The impact of adding a 2-way video monitoring system on falls and costs … February 14, 2024
Remote patient monitoring improves patient falls and reduces harm.
-
psnet.ahrq.gov/node/33579/psn-pdf
September 07, 2019 - Systems Approach
September 7, 2019
Systems Approach. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/systems-approach
PSNet primers are regularly reviewed and updated by the PSNet Editorial Team to ensure that they reflect
current research and practice in the patient safety field.
Background
A 65-year-old …