-
www.ahrq.gov/patient-safety/reports/liability/baker.html
August 01, 2017 - common set of failures by the phases of the L&D care process (e.g., pre-hospital, triage/assessment, monitoring … Monitoring / Laboring
Clinician does not properly assess patient’s condition. … Delivery
Clinician fails to communicate patient risk factors/situation to new clinical team members … medications
3.30
2.76
2.33
2.50
Delivery
Clinician fails to communicate mother's risk factors/situation … medications
3.70
4.33
2.67
1.67
Delivery
Clinician fails to communicate mother's risk factors/situation
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/preventing-cauti-icu-051314.pptx
February 07, 2014 - 40
What looks like a people problem is often a situation problem. … What looks like a people problem is often a situation problem.
Shrinking movie popcorn buckets. … urinary retention protocol
Insertion and maintenance competency evaluations
ED and OR -> ICU processes
Monitoring … Last patient of the morning (11:45 a.m.)
48
75 yo M
Hx of HTN, DM2
Admitted 24 hours earlier “for monitoring … they are at high risk for a sacral decub”
“they are at risk for abdominal compartment syndrome and I’m monitoring
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/spot-coaching.pdf
April 01, 2022 - This mode leads to learned helplessness and an ongoing need for monitoring
and reminding. … called
“coaching” that are not coaching, such as performance counseling, reminding, teaching, and
monitoring … Do you want to talk through
options or explore ways to think about this situation?
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/small_hospitals-slides/Small-and-Rural-Critical-Access-Hospitals-July-19-2011-508.ppt
January 01, 2011 - the purpose of which is to help you realize these goals, by tailoring its tools to your own unit and situation … Monitoring 6. Feedback
Science of Safety
1. Science of safety presentation
2. … Monitoring 6. Feedback
Science of Safety
1. Science of safety presentation
2.
-
psnet.ahrq.gov/web-mm/elopement
July 14, 2010 - Finding that a patient has "gone missing" is a scary situation for providers and patients' families. … without informing staff, response to their absence is based on what is reasonable for the particular situation … policies and procedures in place indicating the steps that personnel are to follow in any elopement situation … Such a protocol may include locating the patient close to the desk, placing an electronic monitoring … In one ED, the use of the RF devices and a new triage protocol reduced the need for one-to-one monitoring
-
psnet.ahrq.gov/issue/adaptive-coordination-cardiac-anaesthesia-study-situational-changes-coordination-patterns
November 15, 2018 - Study
Adaptive coordination in cardiac anaesthesia: a study of situational changes in coordination patterns using a new observation system.
Citation Text:
Manser T, Howard SK, Gaba DM. Adaptive coordination in cardiac anaesthesia: a study of situational changes in coordination patterns…
-
digital.ahrq.gov/ahrq-funded-projects/patient-centered-online-disease-management-using-personal-health-record-system/annual-summary/2011
January 01, 2011 - of patient education and advice were "dispensed" to a patient based on his or her specific clinical situation … would be associated with: 1) improved self-management practices such as medication adherence, home monitoring … biologic measurements such as blood pressure and lipids; 3) better processes of care such as frequency of monitoring
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety.pptx
May 01, 2017 - for Perinatal Care
L&D Unit Safety
6
SPPC Key Perinatal Safety Elements
for L&D Unit Safety
Situation … The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring … The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring
-
psnet.ahrq.gov/issue/potential-uses-ai-perioperative-nursing-handoffs-qualitative-study
September 01, 2021 - Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring
April 26, 2023 … Perspective
Surveillance Monitoring to Improve Patient Safety
-
psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels-and-effective
February 26, 2025 - the importance of having communications and reporting platforms in place such as real time patient monitoring … Technical resources such as real-time data monitoring capabilities and conducting remote tele-consults … Technical resources such as real-time data monitoring capabilities and conducting remote tele-consults … initiate and sustain the innovation; organizations must be able to react to the changing needs of a situation … Strategies for monitoring and updating clinical practice guidelines: a systematic review.
-
psnet.ahrq.gov/node/49749/psn-pdf
December 01, 2015 - attending saw the patient and decided to transfer him to the intensive care unit (ICU) for closer
monitoring … Maintaining the continuous insulin and
dextrose infusions in this situation would have been a better … approach, allowing for closer monitoring and
titration of insulin dosing even while the patient was … of protocols to transition
from IV to subcutaneous insulin
Tasks
High workload and time pressure
situation … management
Attending physician oversight of
plan of care upon ICU transfer
Organizational performance
monitoring
-
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
-
psnet.ahrq.gov/node/33808/psn-pdf
May 01, 2016 - Hospitals should not only have a policy for electrode
changes, but also for monitoring and replacing … .(6) Drew and
colleagues (14) have created a practice standard for ECG monitoring in hospitals that … some alarms are truly
appropriate, and silencing them indiscriminately can lead to a life-threatening situation … Physiologic monitoring alarm load on medical/surgical floors of a community
hospital. … Practice standards for ECG monitoring in hospital settings: executive summary and
guide for implementation
-
www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/tool-obhemorrhage.html
July 01, 2023 - decide its approach to debriefing events based on seriousness of event, expertise available, and data monitoring … context of obstetric hemorrhage, this includes using standard prevention approaches per unit protocol, 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.
-
www.ahrq.gov/ncepcr/tools/confid-report/three-strategies.html
February 01, 2016 - giving physicians the opportunity to make feedback reports work for them
Section 3-3: Postrelease monitoring … This situation enabled the perception to grow that that their report, accessible through a secure data … Postrelease monitoring and evaluation
Like all improvement strategies, physician feedback reports can … ,” can be instructive, more systematic methods for monitoring and evaluating reports include:
Online … Complementary monitoring tools for Web-based reports
Web analytics , many of which are available
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/central-catheter-insertion-notes.docx
April 01, 2022 - CVC Insertion 9
Facilitator Guide
Slide Number and Image
Consider the following situation … Standardization of communication can include using strategies such as:
· SBAR-Q where you explain the situation … Examples of this include procedural insertion notes, monitoring of the central line site, dressing and
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_obhemorrhage.docx
May 01, 2017 - decide its approach to debriefing events based on seriousness of event, expertise available, and data monitoring … context of obstetric hemorrhage, this includes using standard prevention approaches per unit protocol, monitoring … Teamwork Training (TeamSTEPPS) (continued)
Key Perinatal Safety Elements
Examples
Use SBAR (Situation … positive 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.
· C
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Vane.pdf
February 01, 2005 - The
demands and expertise level of these skill sets expand in a deployment situation. … The entire OR staff became responsible for monitoring hospital staff,
patient visitors, and workers … Figure 1 shows a simple and easy-to-follow Infection Control Monitoring
Tool that can be utilized in … any OR/CMS deployment situation (Winthrop T,
personal communication). … It is suggested that this monitoring tool be taken on CD
on any type of deployment so the infection
-
www.ahrq.gov/teamstepps-program/welcome-guides/experienced-trainers.html
July 01, 2023 - Module 3: Situation Monitoring .
Module 4: Mutual Support .
-
www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/action-alliance-webinar-june-2024.pdf
January 01, 2024 - guide participants
through the four key skills for effective
teamwork—communication, leadership,
situation … monitoring, and mutual support