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psnet.ahrq.gov/issue/enhancing-patient-safety-and-risk-management-through-clinical-pathways-oncology
September 13, 2023 - September 13, 2023
Why is safety in intrapartum electronic fetal monitoring so hard?
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psnet.ahrq.gov/web-mm/do-not-disturb
February 03, 2011 - treatment decisions, other team members (the nurse in this case) have responsibility for performance monitoring … and integrity in clinical work with patients and members of clinical teams.( 12 ) Physicians' self-monitoring … shape decisions for future action.( 20 ) What Steps Should Any Health Care Professional Take in This Situation
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psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
December 15, 2024 - Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events … Huddling for high reliability and situation awareness.
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psnet.ahrq.gov/node/49771/psn-pdf
July 01, 2016 - The patient remained in a hospital for 6 more days for monitoring and adjustment of her other medications … frequency of such pairs and triples to
identify and correct the most common picklist problems.(15) Such monitoring … In any complex, local work situation, various
actors make these adjustments in order to get their work
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psnet.ahrq.gov/issue/failure-rescue-and-30-day-hospital-mortality-hospitals-and-without-crew-resource-management
January 26, 2022 - science approach to promote optimal implementation, adoption, use, and spread of continuous clinical monitoring
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psnet.ahrq.gov/node/49639/psn-pdf
November 01, 2011 - Thus, a common definition of a near miss is "An event or a situation that did not produce
patient harm … include direct reporting
by health care workers and also less obtrusive methods, such as active clinical monitoring … may be undesirable, as in the case of repeated reporting of the same incident.(7)
Active clinical monitoring
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psnet.ahrq.gov/issue/effects-electronic-prescribing-community-based-providers-ambulatory-medication-safety
March 04, 2015 - December 16, 2013
Usability of a computerised drug monitoring programme to detect adverse
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psnet.ahrq.gov/issue/safe-opioid-prescribing-prognostic-machine-learning-approach-predicting-30-day-risk-after
July 22, 2020 - Study
Safe opioid prescribing: a prognostic machine learning approach to predicting 30-day risk after an opioid dispensation in Alberta, Canada.
Citation Text:
Sharma V, Kulkarni V, Eurich DT, et al. Safe opioid prescribing: a prognostic machine learning approach to predicting 30-day ris…
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psnet.ahrq.gov/issue/adequacy-hospital-discharge-summaries-documenting-tests-pending-results-and-outpatient-follow
September 23, 2020 - July 21, 2010
Early readmissions to the department of medicine as a screening tool for monitoring
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psnet.ahrq.gov/issue/experience-trigger-tool-identifying-adverse-drug-events-among-older-adults-ambulatory-primary
June 07, 2023 - January 2, 2017
Impact of non-interruptive medication laboratory monitoring alerts in
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psnet.ahrq.gov/issue/decisions-and-repercussions-second-victim-experiences-mothers-medicine-save-dr-mom
May 18, 2022 - ambulatory care safety: a novel method to develop context-sensitive interventions to reduce quality gaps in monitoring
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psnet.ahrq.gov/issue/elder-abuse-and-neglect-overlooked-patient-safety-issue-focus-group-study-nursing-home
March 20, 2019 - Study
Elder abuse and neglect: an overlooked patient safety issue. A focus group study of nursing home leaders' perceptions of elder abuse and neglect.
Citation Text:
Myhre J, Saga S, Malmedal W, et al. Elder abuse and neglect: an overlooked patient safety issue. A focus group study of n…
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psnet.ahrq.gov/issue/safety-management-within-scope-teaching-practical-clinical-skills-framing-errors
December 21, 2022 - Iatrogenic events in neonates: beneficial effects of prevention strategies and continuous monitoring
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psnet.ahrq.gov/issue/safety-culture-operating-room-variability-among-perioperative-healthcare-workers
November 17, 2021 - November 18, 2009
Continuous monitoring of adverse events: influence on the quality of
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psnet.ahrq.gov/issue/disorganized-care-findings-iterative-depth-analysis-surgical-morbidity-and-mortality
October 19, 2022 - October 19, 2022
Recommended guidelines for monitoring, reporting, and conducting research
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psnet.ahrq.gov/node/73553/psn-pdf
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
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psnet.ahrq.gov/periodic-issue/periodic-issue-275
January 29, 2021 - The authors recommend numerous key milestones, including improving measurement methods, routine monitoring … The authors recommend numerous key milestones, including improving measurement methods, routine monitoring … emergence from anesthesia and an unnecessary transfer to the intensive care unit for ventilation and monitoring
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psnet.ahrq.gov/node/49593/psn-pdf
October 01, 2009 - This case highlights two aspects that complicate the situation. … In this situation, a full handoff may not have been done
since the CRNA was not actually leaving the … or aspirated
airway devices, we can potentially extrapolate from a similar but more widely studied situation
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psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
August 21, 2024 - A series of supportive measures need to occur simultaneously (monitoring, laboratory studies, and maintaining … estimation of actual blood lost, can lead to delays in care that may turn an otherwise easily recoverable situation … tools are available.( 6,8 ) Reporting and systems learning actions, including huddles, debriefs, and monitoring … September 12, 2016
WebM&M Cases
Monitoring Fetal Health
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psnet.ahrq.gov/node/853981/psn-pdf
September 27, 2023 - treated him as a “routine boarder” awaiting an
inpatient bed, with insufficiently robust behavioral monitoring … the contrary, self-hanging patients a priori need to be on high-risk suicide precautions with
24/7 monitoring … The patient’s unstable housing situation, fear of traditional health care systems treatments, often agitated