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psnet.ahrq.gov/glossary-0
January 01, 2003 - Close Call
An event or situation that did not produce patient injury, but only because of chance … It may reflect the quality of monitoring, the effectiveness of actions taken once early complications … Near Miss
An event or situation that did not produce patient injury, but only because of chance … Processes encompass all that is done to patients in terms of diagnosis, treatment, monitoring, and counseling … For instance, in an emergency situation, all three of the surgical identification safety checks mentioned
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psnet.ahrq.gov/issue/primary-care-providers-opening-time-sensitive-alerts-sent-commercial-electronic-health-record
March 17, 2021 - Study
Primary care providers' opening of time-sensitive alerts sent to commercial electronic health record InBaskets.
Citation Text:
Cutrona SL, Fouayzi H, Burns L, et al. Primary Care Providers' Opening of Time-Sensitive Alerts Sent to Commercial Electronic Health Record InBaskets. J Ge…
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psnet.ahrq.gov/issue/role-feedback-emergency-ambulance-services-qualitative-interview-study
April 06, 2022 - May 26, 2021
Measurement and monitoring patient safety in prehospital care: a systematic
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psnet.ahrq.gov/issue/multicenter-collaborative-effort-reduce-preventable-patient-harm-due-retained-surgical-items
March 20, 2019 - Study
A multicenter collaborative effort to reduce preventable patient harm due to retained surgical items.
Citation Text:
Carmack A, Valleru J, Randall KH, et al. A multicenter collaborative effort to reduce preventable patient harm due to retained surgical items. Jt Comm J Qual Patient…
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psnet.ahrq.gov/issue/trainees-perceptions-being-allowed-fail-clinical-training-sense-making-model
November 24, 2021 - Study
Trainees' perceptions of being allowed to fail in clinical training: a sense-making model.
Citation Text:
Klasen JM, Teunissen PW, Driessen E, et al. Trainees' perceptions of being allowed to fail in clinical training: a sense‐making model. Med Educ. 2023;57(5):430-439. doi:10.1111…
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psnet.ahrq.gov/issue/safety-checklists-emergency-response-driving-and-patient-transport-experiences-emergency
August 10, 2022 - May 5, 2021
Measurement and monitoring patient safety in prehospital care: a systematic
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psnet.ahrq.gov/issue/understanding-factors-influencing-doctors-intentions-report-patient-safety-concerns
July 29, 2020 - Study
Understanding the factors influencing doctors’ intentions to report patient safety concerns: a qualitative study.
Citation Text:
Rich A, Viney R, Griffin A. Understanding the factors influencing doctors' intentions to report patient safety concerns: a qualitative study. J R Soc Med…
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psnet.ahrq.gov/issue/adopting-high-reliability-organization-principles-lead-large-scale-clinical-transformation
November 21, 2021 - March 27, 2024
Why is safety in intrapartum electronic fetal monitoring so hard?
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psnet.ahrq.gov/issue/grading-recommendations-enhanced-patient-safety-sentinel-event-analysis-recommendation
April 15, 2020 - support alerts tailored to intensive care on the administration of high-risk drug combinations, and their monitoring
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psnet.ahrq.gov/node/49784/psn-pdf
February 01, 2017 - organization to first evaluate and then select the appropriate methodology or device for the
testing situation … When patients use point-of-care testing at home, such as international normalized ratio for monitoring … Evaluate available testing methods and devices first, then select those appropriate to the testing
situation
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psnet.ahrq.gov/node/49407/psn-pdf
July 01, 2003 - Medication errors specific to oral anticoagulants generally occur either due to inadequate monitoring … For outpatients, less frequent
monitoring can be performed; however, monitoring should occur at least … Once a stable dosage of warfarin is achieved, the frequency of INR monitoring can be reduced to
weekly … If medications or diet are changed, increased monitoring
of the INR is required.(8)
When patients present … In the early days of therapy, fail-safe plans should be in place for frequent INR monitoring.
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psnet.ahrq.gov/issue/how-avoid-catastrophic-events-ward
February 03, 2011 - support alerts tailored to intensive care on the administration of high-risk drug combinations, and their monitoring
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psnet.ahrq.gov/issue/role-dynamic-trade-offs-creating-safety-qualitative-study-handover-across-care-boundaries
January 21, 2015 - January 21, 2015
Hassle in the dispensary: pilot study of a proactive risk monitoring
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psnet.ahrq.gov/web-mm/room-without-orders
September 01, 2011 - their unit, which involves myriad activities: performing daily assessments, administering medications, monitoring … Forty-four percent of nurse respondents reported missing assessment activities (i.e., patient assessments, monitoring … The Safety and Quality of Long Term Care
September 1, 2011
Evaluating situation … 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/perspective/conversation-james-augustine-md
July 28, 2021 - are there to provide guidance for actions that occur outside of those medical protocols, such as a situation … In the early days, we began to use basic interventions like IV [intravenous] fluid and cardiac monitoring … Colton Hood about Remote Patient Monitoring
March 15, 2023
Interview
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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/understanding-facilitators-and-barriers-barcode-medication-administration-nursing-staff-using
August 28, 2024 - February 20, 2019
Why is safety in intrapartum electronic fetal monitoring so hard?
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_stable_airway_slides_final.pptx
January 01, 2024 - Although routine continuous monitoring of oxygen saturation has been shown to decrease rates of some … a mechanically ventilated patient, three questions should be considered: (1) Why are we monitoring, … (2) How good are the monitoring tools, and (3) Does monitoring lead to a change in management improving … Monitoring During Mechanical Ventilation. Respir Care. 2020;65(6):832-846. … Pulse oximetry for perioperative monitoring. Cochrane Anaesthesia Group, ed.
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psnet.ahrq.gov/node/72586/psn-pdf
December 23, 2020 - A timeline for the transition had not been established, given the complexity of
the situation and the … to understand.10,11
Appreciation involves the application of information presented to one’s own situation … It was a
nuanced situation that required explicit communication with multiple parties to fully understand … The receiving team could have stated their understanding of the patient’s goals and which monitoring, … treatment,” you miss the reality that in order to meet his goal, his respiratory status needed continued
monitoring
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psnet.ahrq.gov/perspective/conversation-didier-pittet-md-ms
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.