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psnet.ahrq.gov/node/855058/psn-pdf
October 31, 2023 - lot about de-escalation techniques, and I think those are important when it becomes apparent
that a situation … At some point, it’s almost too late for de-escalation when a situation reaches the point of
reporting … Organizations should be thinking about
staffing, policies around reporting, monitoring, and being alert … It’s
important that staff know what to do if a situation escalates and what resources are available
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psnet.ahrq.gov/node/73998/psn-pdf
October 27, 2021 - Proper Intravenous Catheter Site Monitoring and Detection of Infiltration
Intravenous infiltration is
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psnet.ahrq.gov/node/49683/psn-pdf
April 01, 2013 - mellitus, and significant weight gain.(3,4) Use of these medications therefore
requires careful metabolic monitoring … Any shift in his medication regimen or social situation would therefore need careful
consideration. … process, it could have helped to coordinate
the aftercare plan, including home visits to assist with monitoring
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psnet.ahrq.gov/node/33699/psn-pdf
August 01, 2010 - Structured communication tools such as situation-background-
assessment-recommendation (SBAR) show promise … Training in AMCs to improve
teamwork skills may include mutual performance monitoring and backup support … Building a high reliability organization through a multi-
method approach to monitoring the practice
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psnet.ahrq.gov/node/49394/psn-pdf
April 01, 2003 - Prior to inducing labor, fetal
heart rate monitoring and an ultrasound assessment of the fetus were … psnet.ahrq.gov//#references
It is important for each new team of caregivers to re-evaluate the clinical situation … Induction of labor as compared
with serial antenatal monitoring in post-term pregnancy.
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psnet.ahrq.gov/web-mm/picture-speaks-1000-words
July 16, 2015 - Following this case, data safety and monitoring policies were changed. … example, whether the hospital's chair of radiology, risk manager, and privacy officer knew about the situation … Once the case was reviewed and the system problems defined, data monitoring policies were changed and
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psnet.ahrq.gov/web-mm/walking-out-hospital-after-attempted-suicide
March 29, 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
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psnet.ahrq.gov/node/49716/psn-pdf
August 21, 2014 - In a crisis situation, particularly one in
which large volumes of fluids or vasoactive medications are … Lastly, once the urgency of the situation has
resolved, replacing the IO needle with more long-term
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psnet.ahrq.gov/node/74121/psn-pdf
November 30, 2021 - Medical devices are a valuable adjunct for
monitoring patient status since physiological triggers are … There are three types of alarms
generated by monitoring devices: arrhythmia alarms (change in cardiac … and include appropriate responses in high-risk areas, setting alarm limits
relevant to the clinical situation … Alarm fatigue is a well-known result of frequent false alarms from monitoring devices. … Adequate
staffing and training are critically important in the management of monitoring devices.
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psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
January 04, 2024 - the exchange of knowledge and information across multiple healthcare providers in any patient care situation … represent active and latent factors or failure modes that may become active at any time, place, or situation … During the case, the anesthesiologist placed devices on the skin and inserted a central venous line for monitoring … the retained sponge because they thought the sponge radiopaque markers were just wires from electrode monitoring
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psnet.ahrq.gov/perspective/innovations-promoting-hand-hygiene-compliance
May 01, 2014 - Another system for monitoring hand hygiene is to assess handwash product utilization, which can be used … These monitoring methods can vary; some use sensors that detect alcohol vapors on the HCW's hands ( 13 … Performance monitoring and feedback was a third element of the strategy. … The benefit of direct monitoring is that you know exactly what you are observing, and when you offer … But it is feasible once people have really standardized the monitoring of hand hygiene performance.
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psnet.ahrq.gov/node/841306/psn-pdf
December 14, 2022 - Resilient Healthcare and the Safety-I and Safety-II
Frameworks
December 14, 2022
Deutsch ES, Van CM, Mossburg SE. Resilient Healthcare and the Safety-I and Safety-II Frameworks.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/resilient-healthcare-and-safety-i-and-safety-ii-frameworks
Resilient healthca…
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psnet.ahrq.gov/issue/safe-practice-recommendations-use-copy-forward-nursing-flow-sheets-hospital-settings
May 18, 2022 - January 21, 2019
Improving situation awareness to reduce unrecognized clinical deterioration
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psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
September 01, 2004 - 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/periodic-issue/periodic-issue-352
July 08, 2022 - of risk stratification to understand patient risk for oversedation, and strategies for appropriate monitoring
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psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy
September 07, 2019 - prescribing of PIMs in hospital settings. 12
Finally, deprescribing is an ongoing process that requires monitoring
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psnet.ahrq.gov/node/33606/psn-pdf
September 07, 2019 - interventions to reduce opioid prescribing include
measures such as state-level prescription drug monitoring … psnet.ahrq.gov/primer/measurement-patient-safety
https://psnet.ahrq.gov/issue/implementation-prescription-drug-monitoring-programs-associated-reductions-opioid-related
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psnet.ahrq.gov/issue/nature-surgical-error-cautionary-tale-and-call-reason
September 12, 2007 - March 29, 2012
Physicians' perspectives regarding prescription drug monitoring program … May 19, 2010
Discrepant perceptions of communication, teamwork and situation awareness … November 7, 2018
Effectiveness of continuous or intermittent vital signs monitoring in
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psnet.ahrq.gov/node/49796/psn-pdf
June 01, 2017 - ventilation, which increases the likelihood and risk of an air leak).(11) During a clamp trial, close
monitoring … case include lack of clear guidelines on chest tube removal, such as
assigning responsibility for monitoring … tube care path that outlines
an algorithm for safe removal of chest tubes, including frequency of monitoring
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psnet.ahrq.gov/web-mm/near-miss-bedside-medications
February 01, 2006 - 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