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psnet.ahrq.gov/issue/understanding-and-learning-organisational-failure
April 19, 2011 - December 8, 2021
Situation awareness and the mitigation of risk associated with patient … September 1, 2011
Hassle in the dispensary: pilot study of a proactive risk monitoring
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psnet.ahrq.gov/node/50844/psn-pdf
January 29, 2020 - psnet.ahrq.gov/issue/incidence-patterns-and-prevention-wrong-site-surgery
https://psnet.ahrq.gov/issue/improving-situation-awareness-reduce-unrecognized-clinical-deterioration-and-serious-safety … https://psnet.ahrq.gov//#7
https://psnet.ahrq.gov//#8
https://psnet.ahrq.gov/issue/administering-and-monitoring-high-alert-medications-acute-care … Improving situation awareness to reduce unrecognized
clinical deterioration and serious safety events … Huddling for high reliability and situation awareness.
BMJ Qual Saf. 2013;22(11):899-906.
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psnet.ahrq.gov/issue/practice-advisory-intraoperative-awareness-and-brain-function-monitoring
July 16, 2018 - Review
Practice Advisory on Intraoperative Awareness and Brain Function Monitoring … Practice advisory for intraoperative awareness and brain function monitoring: a report by the american … This clinical guideline on minimizing intraoperative awareness through appropriate monitoring has been … Practice advisory for intraoperative awareness and brain function monitoring: a report by the american
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psnet.ahrq.gov/issue/iatrogenic-events-neonates-beneficial-effects-prevention-strategies-and-continuous-monitoring
February 20, 2008 - Iatrogenic events in neonates: beneficial effects of prevention strategies and continuous monitoring … Iatrogenic events in neonates: beneficial effects of prevention strategies and continuous monitoring. … This study adopted an anonymous monitoring system for iatrogenic events to drive prevention initiatives … Iatrogenic events in neonates: beneficial effects of prevention strategies and continuous monitoring.
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psnet.ahrq.gov/issue/achieving-successful-patient-safety-program-implementation-harm-reduction-strategy
February 22, 2023 - January 2, 2011
APSF endorsed statement on revising recommendations for patient monitoring … October 26, 2022
Three quarters of preventable patient harm stems from situation awareness
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psnet.ahrq.gov/node/862983/psn-pdf
February 28, 2024 - This situation needs to be remedied emergently to prevent hypoxemia and/or hypercapnic
https://psnet.ahrq.gov … 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 … Approaches to Improving Patient Safety
Anesthesia clinicians must monitor the patient carefully
Vigilant monitoring … surgeon, the anesthesia team, the scrub and circulating nurses as well as
the neurophysiologist who is monitoring
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psnet.ahrq.gov/issue/patient-safety-incidents-associated-airway-devices-critical-care-review-reports-uk-national
March 12, 2025 - The report makes recommendations for the proper use of monitoring equipment to ensure safety for intubated … May 30, 2012
Team situation awareness and the anticipation of patient progress during
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psnet.ahrq.gov/issue/nonopioid-directives-unintended-consequences-operating-room
September 07, 2022 - It discusses the potential for adverse impacts of the strategy while recognizing the unique situation … room went into chaos because of that thing in the corner": unintended consequences of a central fetal monitoring
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psnet.ahrq.gov/node/848124/psn-pdf
April 26, 2023 - Susan McGrath, PhD and George
Blike, MD about Surveillance Monitoring
April 26, 2023
In Conversation … Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring. PSNet
[internet]. 2023. … The issue is your system must be tuned to say, “Is this the
type of situation that would trigger a rapid … I know some of your work was about
integrating surveillance monitoring into workflows. … If you start adding more
sensors and more alarms, then you’re going to be right back in that situation
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psnet.ahrq.gov/issue/walking-plank-experimental-paradigm-investigate-safety-voice
January 18, 2023 - more likely to speak up when they received specific information about safety risks in an experimental situation … The Healthcare Complaints Analysis Tool: development and reliability testing of a method for service monitoring
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psnet.ahrq.gov/node/49850/psn-pdf
January 01, 2019 - set in the electronic medical record had
undergone significant revision and now contained dosing and monitoring … proper bolus dosing, correct rate of maintenance
infusion, and appropriate timing of anticoagulation monitoring … The case indicates
that the heparin infusion order set in question "now contained dosing and monitoring … order set is not appropriate for a given patient due to
specific aspects of that patient's medical situation … Therefore, a best practice in such a situation would be to augment such electronic communications and
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psnet.ahrq.gov/node/33590/psn-pdf
September 07, 2019 - culture
of safety, responding to patient and staff concerns, supporting efforts to improve safety, and monitoring … not limited to)
formulating the organizational mission and key goals, ensuring financial viability, monitoring … This situation is changing, driven by data on the influence of leadership engagement, as well as
greater … practices include structured use of
data to enhance care by setting specific quality goals and regularly monitoring
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psnet.ahrq.gov/node/44307/psn-pdf
November 06, 2015 - skills used by anaesthetic technicians
in critical incidents reported to the Australian Incident
Monitoring … non-technical skills used by anaesthetic technicians in critical incidents
reported to the Australian Incident Monitoring
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psnet.ahrq.gov/issue/little-help-my-friends-positive-contribution-teamwork-safety-behaviour-public-hospitals
July 22, 2020 - July 28, 2021
The impact of an intervention to improve intrapartum maternal vital sign monitoring … June 8, 2011
Discrepant perceptions of communication, teamwork and situation awareness
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psnet.ahrq.gov/issue/causes-medical-errors-obstetrics-and-gynaecology
May 01, 2019 - January 4, 2015
Discrepant perceptions of communication, teamwork and situation awareness … support alerts tailored to intensive care on the administration of high-risk drug combinations, and their monitoring
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psnet.ahrq.gov/periodic-issue/periodic-issue-314
October 27, 2021 - Study
Optimizing situation awareness to reduce emergency transfers in hospitalized children … Study
Optimizing situation awareness to reduce emergency transfers in hospitalized children … The commentary discusses the importance intraoperative monitoring of intravenous catheters and the use … The commentary discusses the limitations of prescription drug monitoring program (PDMP) data for patients
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psnet.ahrq.gov/issue/implementing-strategies-identify-and-mitigate-adverse-safety-events-case-study-unplanned
May 24, 2012 - They advocate for the use of continuous monitoring tools to help alert teams to possible safety events … February 3, 2010
Safety as a criterion for quality: The Critical Nursing Situation Index
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psnet.ahrq.gov/node/865656/psn-pdf
April 24, 2024 - Due
to the urgency of the situation, the primary nurse overrode the automated dispensing unit and mistakenly … He was placed on cardiorespiratory and end tidal
carbon dioxide monitoring. … configuring the electronic health record to flow overrides into
the pharmacist queue to allow for real-time monitoring … improves the patient’s psychotic symptoms, agitation may improve after a single dose, but continued
monitoring
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psnet.ahrq.gov/periodic-issue/periodic-issue-345
May 16, 2022 - Review
Root cause analysis using the prevention and recovery information system for monitoring … One method of RCA is the Prevention and Recovery Information System for Monitoring and Analysis (PRISMA … Identifying Safety Events in the Prehospital Setting May 16, 2022
This piece focuses on measuring and monitoring
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psnet.ahrq.gov/issue/intervention-increase-situational-awareness-and-culture-mutual-care-foco-and-its-effects
November 21, 2021 - January 17, 2018
Why is safety in intrapartum electronic fetal monitoring so hard?