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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/846768/psn-pdf
March 29, 2023 - continuous positive airway pressure via face mask, and sitting him upright might have
stabilized the situation … The American
Society of Anesthesiology now recommends the use of quantitative neuromuscular monitoring … recovery from neuromuscular blocking drugs prior to extubation.26 This quantitative
neuromuscular monitoring … Monitoring the
patient’s respiration and oxygenation is especially important immediately following extubation … SR, Weigel WA, Todd MM, et al. 2023 American Society of Anesthesiologists Practice
Guidelines for Monitoring
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psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph
April 26, 2023 - signals that the process isn't quite working right, that the safety protocol doesn't quite fit the situation … That a machine maintenance program wasn't quite designed to do x, y, or z, and that's the situation … Further complicating our situation in health care is that health care workers in virtually every organization … We found too many instances where technology including EHRs, IV pumps, and monitoring systems don't talk … Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring
April 26, 2023
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psnet.ahrq.gov/issue/mental-models-basic-concept-human-factors-design-infection-prevention
April 26, 2017 - Commentary
Mental models: a basic concept for human factors design in infection prevention.
Citation Text:
Sax H, Clack L. Mental models: a basic concept for human factors design in infection prevention. J Hosp Infect. 2015;89(4):335-9. doi:10.1016/j.jhin.2014.12.008.
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psnet.ahrq.gov/node/33766/psn-pdf
May 01, 2014 - Performance monitoring
and feedback was a third element of the strategy. … DP: Auditing is performed using infection control practitioners monitoring practices in different wards … The benefit of direct monitoring is
that you know exactly what you are observing, and when you offer … Thus, a system monitoring only the use of alcohol-based hand rub will give only a partial
idea of the … But it is feasible
once people have really standardized the monitoring of hand hygiene performance.
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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/node/33642/psn-pdf
November 01, 2006 - DN: First, we need automatic equipment that at least can notice when we're reaching an untenable
situation … Then maybe we could change the situation. … Instead of standing over the patient and
monitoring them clinically, you are now sitting in front of
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psnet.ahrq.gov/web-mm/silent-pain-neck
August 19, 2020 - Monitoring Specific protocols for monitoring patients after neck surgery vary across institutions. … Ultrasound may have a role in monitoring for neck hematomas, but it has not been systematically studied … It cannot be emphasized enough that this is a high-pressure and risky situation, and the caregivers should … This approach requires careful monitoring of the airway while the patient is being transported to the … However, careful monitoring in a unit capable of providing early airway and surgical intervention is
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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/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/node/49482/psn-pdf
May 01, 2005 - Fetal monitoring was normal and the patient was discharged home. … In either situation,
clear communication between the emergency physician and obstetrician is important … urgent or emergent complaints, unless
clearly of no threat to the fetus, will undergo formal fetal monitoring … In an ED where a pregnant
woman may require a prolonged stay, a protocol to provide fetal monitoring … as in our institution, fetal
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monitoring
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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/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/issue/each-baby-counts-key-messages-2015
July 26, 2017 - A WebM&M commentary discusses how lapses in fetal monitoring can miss signs of distress that result
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psnet.ahrq.gov/node/49857/psn-pdf
March 01, 2019 - phases of the medication-use
process (prescribing, transcribing, storage/dispensing, administering, and monitoring … prescribing (17%).(3,4) The main causes of subcutaneous insulin
administration errors are incorrect monitoring … such as forms and checklists, face-to-face and electronic communications, and
frameworks like SBAR (Situation … this case, a discussion regarding
administration of the subcutaneous insulin, the plan for glucose monitoring
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psnet.ahrq.gov/primer/teamwork-training
September 15, 2024 - coupling teamwork training programs with more specific efforts to structure communication, such as SBAR (situation
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psnet.ahrq.gov/node/33705/psn-pdf
January 01, 2011 - As a direct result of this claim study, the
committee developed standards for pulse oximetry monitoring … Standards for patient monitoring
during anesthesia at Harvard Medical School. … Medication or treatment errors requiring clinical intervention (invasive procedure(s), increased
monitoring … The attending should also be contacted if:
Any trainee feels that a situation is more complicated than
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psnet.ahrq.gov/issue/canadian-patient-safety-institute
August 24, 2022 - Measurement and Monitoring of Safety Through the Eyes of Patients and Their Care Partners.