-
psnet.ahrq.gov/node/49757/psn-pdf
April 01, 2016 - Arguably the bedside is the most important situation for the
physician to perceive and understand. … of interest is the
first step in recognizing what might be wrong with the situation, and it supports … Situation awareness global assessment technique (SAGAT). … Toward a theory of situation awareness in dynamic systems. Hum Factors. 1995;37:32-64. … Beyond monitoring: distributed situation awareness in
anaesthesia. Br J Anaesth. 2010;105:83-90.
-
psnet.ahrq.gov/primer/high-reliability
January 29, 2020 - reluctance to simplify explanations for operations, successes, and failures; sensitivity to operations (situation … This sensitivity is often referred to as "big picture understanding" or "situation awareness." … Thus, people in HROs know that in a crisis or emergency the person with greatest knowledge of the situation … Deference to local and situation expertise results in a spirit of inquiry and de-emphasis on hierarchy … Teams cultivate situation assessment and cross monitoring so they may identify potential safety threats
-
psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
January 29, 2021 - This situation needs to be remedied emergently to prevent hypoxemia and/or hypercapnic acidosis, which … Without such communication, it would have taken much longer to rectify the situation. … spinal motor pathways during the operation. 12 Neuromuscular blocking drugs should be avoided when monitoring … surgeon, the anesthesia team, the scrub and circulating nurses as well as the neurophysiologist who is monitoring … Beyond the surgical safety checklist: using intraoperative handoff to facilitate team situation
-
psnet.ahrq.gov/issue/insights-problem-alarm-fatigue-physiologic-monitor-devices-comprehensive-observational-study
July 17, 2013 - are too frequent or perceived to be clinically irrelevant, can lead to lack of awareness of an unsafe situation … This retrospective review examined all alarm data regarding physiologic monitoring, including electrocardiogram
-
psnet.ahrq.gov/issue/novel-study-situational-awareness-among-out-hospital-providers-during-online-clinical
June 08, 2022 - Situational awareness (SA) requires recognizing situations, interpreting them, and predicting how the situation
-
psnet.ahrq.gov/issue/using-ventilator-splitters-during-covid-19-pandemic-letter-health-care-providers
June 02, 2021 - This situation can reduce the effectiveness of monitoring patients on shared devices and introduce
-
psnet.ahrq.gov/issue/why-patient-summaries-electronic-health-records-do-not-provide-cognitive-support-necessary
January 18, 2013 - care unit nurses' information needs and recommendations for integrated displays to improve nurses' situation … Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring
April 26, 2023 … Perspective
Surveillance Monitoring to Improve Patient Safety
-
psnet.ahrq.gov/issue/customer-focused-incident-monitoring-anaesthesia
April 24, 2018 - Study
Customer focused incident monitoring in anaesthesia. … Customer focused incident monitoring in anaesthesia. Anaesthesia. 2007;62(6):586-90. … Customer focused incident monitoring in anaesthesia. Anaesthesia. 2007;62(6):586-90.
-
psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-acute-hospital-care-units
April 26, 2023 - Surveillance Monitoring
Surveillance Monitoring is an electronic system for continuously monitoring … Surveillance monitoring differs from clinically indicated continuous monitoring in higher-acuity settings … continuous monitoring approaches. … The issue is your system must be tuned to say, “Is this the type of situation that would trigger a rapid … If you start adding more sensors and more alarms, then you’re going to be right back in that situation
-
psnet.ahrq.gov/issue/administering-saline-flush-site-unseen-can-lead-wrong-route-error
June 10, 2018 - From the Same Author(s)
Fatal PCA adverse events continue to happen...better patient monitoring … May 2, 2018
Remote CPOE error—a situation that's more than remotely possible.
-
psnet.ahrq.gov/issue/apsf-20-year-anniversary-first-patient-safety-organization-past-present-future
October 26, 2022 - October 25, 2023
APSF endorsed statement on revising recommendations for patient monitoring … March 10, 2021
Three quarters of preventable patient harm stems from situation awareness
-
psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
August 20, 2018 - Department of Defense, consists of four core teachable competencies: communication, team leadership, situation … monitoring, and mutual support. … The SBAR or Situation, Background, Assessment, and Recommendation/Request tool represents a useful … The third skill is situational monitoring, which is the responsibility of all team members. … A helpful tool for situational monitoring is STAR: Stop, Think, Act, and Review.
-
psnet.ahrq.gov/node/49853/psn-pdf
February 01, 2019 - of the procedure, the PACU anesthesiologist ordered him to be placed on continuous pulse-oximetry
monitoring … a reminder to document
the intrahospital transfer in the patient's medical record, and rechecking monitoring … transfer, communication strategies such as
closed-loop communication and frameworks such as SBAR [Situation … Safe transport requires trained personnel and appropriate level of monitoring. … SBAR Tool: Situation-Background-Assessment-Recommendation.
-
psnet.ahrq.gov/issue/reducing-medical-error-military-health-system-how-can-team-training-help
March 29, 2007 - The program consists of teaching core skills in leadership, situation monitoring, team support, and communication
-
psnet.ahrq.gov/issue/promethazine-adverse-events-after-implementation-medication-shortage-interchange
October 26, 2010 - number of prescribed medications a patient is currently receiving can affect his or her safety in this situation … July 20, 2022
Assessing and monitoring override medications in automated dispensing devices
-
psnet.ahrq.gov/issue/frequency-and-type-situational-awareness-errors-contributing-death-and-brain-damage-closed
September 01, 2021 - September 13, 2017
Situation awareness errors in anesthesia and critical care in 200 … June 21, 2016
Situation awareness errors in anesthesia and critical care in 200 cases
-
psnet.ahrq.gov/issue/training-situational-awareness-reduce-surgical-errors-operating-room
November 21, 2012 - October 19, 2012
Practice Advisory on Intraoperative Awareness and Brain Function Monitoring
-
psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport
June 16, 2021 - length of the procedure, the PACU anesthesiologist ordered him to be placed on continuous pulse-oximetry monitoring … , a reminder to document the intrahospital transfer in the patient's medical record, and rechecking monitoring … information transfer, communication strategies such as closed-loop communication and frameworks such as SBAR [Situation … Safe transport requires trained personnel and appropriate level of monitoring. … SBAR Tool: Situation-Background-Assessment-Recommendation.
-
psnet.ahrq.gov/issue/medical-harm-historical-conceptual-and-ethical-dimensions-iatrogenic-illness
May 13, 2020 - factors from both the clinical and administrative sides of medicine are presented as contributors to the situation … September 29, 2017
Prescription Drug Monitoring Programs: Evidence-based Practices to
-
psnet.ahrq.gov/issue/transformation-health-care-front-line
July 24, 2017 - Download Citation
Related Resources From the Same Author(s)
Improving situation … August 27, 2013
Selection of indicators for continuous monitoring of patient safety: