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psnet.ahrq.gov/node/49446/psn-pdf
August 30, 2021 - glucose levels, alterations in rate and IV fluid
type if the patient is NPO, and frequency of glucose monitoring … carefully developed decision support, to assist in adjusting
insulin drips, and standardization of glucose monitoring … A pop-
up flag could have alerted the surgeon to ensure the insulin drip was appropriate for the situation … Protocols for tighter glucose control must incorporate adequate monitoring frequency to avoid
hypoglycemia
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psnet.ahrq.gov/issue/creating-effective-quality-improvement-collaboratives-multiple-case-study
December 19, 2012 - July 24, 2019
Selection of indicators for continuous monitoring of patient safety: recommendations
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psnet.ahrq.gov/issue/automation-failures-and-patient-safety
November 21, 2012 - August 25, 2021
Nonoperating room anaesthesia: safety, monitoring, cognitive aids and
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psnet.ahrq.gov/issue/observational-study-practice-during-transfer-patients-anaesthetic-room-operating-theatre
September 27, 2016 - Study
An observational study of practice during transfer of patients from anaesthetic room to operating theatre.
Citation Text:
Broom MA, Slater J, Ure DS. An observational study of practice during transfer of patients from anaesthetic room to operating theatre. Anaesthesia. 2006;61(10…
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psnet.ahrq.gov/issue/medication-safety-primary-care-practice-results-pprnet-quality-improvement-intervention
April 23, 2008 - April 23, 2008
Medication prescribing and monitoring errors in primary care: a report
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psnet.ahrq.gov/issue/duration-anesthesia-indicator-morbidity-and-mortality-office-based-facial-plastic-surgery
March 19, 2018 - Study
Duration of anesthesia as an indicator of morbidity and mortality in office-based facial plastic surgery: a review of 1200 consecutive cases.
Citation Text:
Gordon NA, Koch ME. Duration of anesthesia as an indicator of morbidity and mortality in office-based facial plastic surger…
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psnet.ahrq.gov/web-mm/wrong-route-nutrients
September 04, 2010 - 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/issue/frequency-risk-factors-potentially-increase-harm-medications-older-adults-receiving-primary
May 18, 2022 - January 19, 2014
Usability of a computerised drug monitoring programme to detect adverse
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psnet.ahrq.gov/issue/people-systems-and-safety-resilience-and-excellence-healthcare-practice
March 04, 2020 - December 5, 2018
Ergonomic and human factors affecting anesthetic vigilance and monitoring
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psnet.ahrq.gov/issue/evolution-patient-safety-procedures-oral-surgery-department
November 16, 2022 - April 24, 2018
Analysing potential harm in Australian general practice: an incident-monitoring
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psnet.ahrq.gov/issue/seips-30-human-centered-design-patient-journey-patient-safety
September 11, 2019 - Related Resources
Interventions to reduce medication dispensing, administration, and monitoring
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psnet.ahrq.gov/issue/impact-pharmacist-provided-medication-therapy-management-healthcare-quality-and-utilization
November 16, 2022 - impacts of a pharmacist-managed outpatient clinic and chemotherapy-directed electronic order sets for monitoring
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psnet.ahrq.gov/issue/analysis-intervention-employability-pharmacy-related-medication-safety-reports-tertiary
November 21, 2021 - April 26, 2023
Why is safety in intrapartum electronic fetal monitoring so hard?
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psnet.ahrq.gov/issue/understanding-unwarranted-variation-clinical-practice-focus-network-effects-reflective
March 31, 2021 - May 19, 2021
A meta-review of methods of measuring and monitoring safety in primary care
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psnet.ahrq.gov/issue/exploring-impact-employee-engagement-and-patient-safety
July 27, 2022 - December 16, 2020
A meta-review of methods of measuring and monitoring safety in primary
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psnet.ahrq.gov/issue/effect-communication-errors-during-calls-antimicrobial-stewardship-program
June 22, 2022 - Study
Effect of communication errors during calls to an antimicrobial stewardship program.
Citation Text:
Linkin DR, Fishman NO, Landis R, et al. Effect of communication errors during calls to an antimicrobial stewardship program. Infect Control Hosp Epidemiol. 2007;28(12):1374-1381.
…
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psnet.ahrq.gov/periodic-issue/periodic-issue-419
November 29, 2023 - with electronic health record modernization that establish cultural, functionality, staff, design, and monitoring … Lack of respect for the concerns of patients and sensitivity to their situation detract from their safety … Quantitative blockade monitoring revealed a “train of four” (TOF) ratio less than 70%, so she was given
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psnet.ahrq.gov/web-mm/communication-failure-whos-charge
April 01, 2018 - After stabilizing and monitoring the child's respiratory status, the ICU attending returned home. … Adequate systems were not in place to establish, review, or revise team understanding of the situation … an inquiry process that engages all relevant team members in reassessing their understanding of the situation … the child's condition are rather different than the implications of recognizing the severity of the situation
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psnet.ahrq.gov/issue/disruptions-surgical-flow-and-their-relationship-surgical-errors-exploratory-investigation
August 26, 2011 - Study
Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation.
Citation Text:
Wiegmann DA, Elbardissi AW, Dearani JA, et al. Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Surgery. 2007;…
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psnet.ahrq.gov/issue/defining-attributes-patient-safety-through-concept-analysis
May 08, 2013 - disparities in the frequency of patient safety events: results from the National Medicare Patient Safety Monitoring