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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:
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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/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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digital.ahrq.gov/icd
January 01, 2023 - These uses include the analysis of the general health situation of population groups and monitoring of
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psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers
December 21, 2017 - Consequently, the patient received an excessive amount of the medication, which resulted in a near code situation … Patient monitoring needs should also be assessed. … Monitoring high-risk cardiac patients during transportation in hospital. … An analysis of the reports submitted to the Australian Incident Monitoring Study in Intensive Care. … care unit nurses' information needs and recommendations for integrated displays to improve nurses' situation
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psnet.ahrq.gov/issue/can-standard-configuration-cardiac-monitor-lead-medical-errors-under-stress-induction
May 19, 2021 - Study
Can the standard configuration of a cardiac monitor lead to medical errors under a stress induction?
Citation Text:
Dzisko M, Lewandowska A, Wudarska B. Can the standard configuration of a cardiac monitor lead to medical errors under a stress induction? Sensors (Basel). 2022;22(9):…
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www.ahrq.gov/teamstepps-program/curriculum/implement/activity/coach.html
June 01, 2023 - It requires routine monitoring and ongoing assessment of performance. … practice TeamSTEPPS in several ways, such as:
Asking team members how they might have approached a situation … Faced with an individual whose personal situation is interfering with their performance, however, you … of professional assistance and adjust the coaching process to support getting through the personal situation … Following Through – Keeping your commitments; monitoring outcomes of the coaching process and providing
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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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www.uspreventiveservicestaskforce.org/home/getfilebytoken/EHr5y9g2_QfQzWKBCNq7rX
November 01, 2020 - Clinicians should understand the evidence but individualize decision making to the specific patient or situation … motivational interviewing and behavioral change
techniques such as goal setting, active use of self-monitoring … Clinicians should understand the evidence but individualize decision making to the specific patient or situation
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb5txt.html
December 01, 2017 - Your perception of the behavior may be very different from the actual situation. … Situation.
Location.
Resident motivation, feelings and agenda. … history
Step 3
Circumstances
Time
Frequency
Location
Persons present
Situation
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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/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/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/node/851099/psn-pdf
June 28, 2023 - An arterial line was inserted into the left radial artery to enable close monitoring of the
patient’ … In this situation, backflow from
the catheter is very sluggish and fluids infuse into the artery. … complete thrombosis on ultrasound after removal of the catheter.23 Yet hand ischemia is very rare in this
situation … Some authors recommend
maintaining the arterial catheter in place in this situation to facilitate administering … Regular visual monitoring of a limb with an arterial line is especially important in sedated patients
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/tool-shoulder-dystocia.html
July 01, 2023 - with fetal condition per National Institute for Child Health and Human Development electronic fetal monitoring … decide its approach to debriefing events based on seriousness of event, expertise available, and data monitoring … risk awareness for all patients, timely recognition of a shoulder dystocia diagnosis, awareness and monitoring … approach to emphasize "what is right, not who is right":
D: Describe the specific behavior or situation … E: Express how the situation makes you feel or concerns you.
S: Suggest other alternatives.
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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
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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
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/prescribers-facilitator-guide.docx
June 01, 2021 - SBAR stands for Situation, Background, Assessment, and Recommendation. … First, the Situation. State who you are calling about and why. Provide a 5- to 10-second summary. … Situation: Hello Dr. K., I am calling about Ms. R., the 92-year-old resident in room 332. … Situation: “Hello, I am calling about Mr. B. in room 214. … Together, the nurse and on-call clinician decided on a plan of active monitoring to include vital signs
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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.