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psnet.ahrq.gov/issue/world-health-organization-world-federation-societies-anaesthesiologists-who-wfsa
November 16, 2015 - related to professional qualification; facilities and equipment ; medications and intravenous fluids; monitoring … October 10, 2012
Recommended guidelines for monitoring, reporting, and conducting research … Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring
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psnet.ahrq.gov/issue/operational-failures-general-practice-consensus-building-study-priorities-improvement
February 07, 2024 - Related Resources From the Same Author(s)
Why is safety in intrapartum electronic fetal monitoring … May 13, 2020
Effectiveness and safety of pulse oximetry in remote patient monitoring … August 3, 2022
Impact of non-interruptive medication laboratory monitoring alerts in
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www.ahrq.gov/patient-safety/settings/hospital/match/table-6.html
August 01, 2012 - Multivitamin was not ordered on admission
D
Error that reached the patient and could have necessitated monitoring
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www.ahrq.gov/es/patient-safety/settings/hospital/match/table-6.html
August 01, 2012 - Multivitamin was not ordered on admission
D
Error that reached the patient and could have necessitated monitoring
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www.ahrq.gov/patient-safety/quality-resources/tools/chtoolbx/uses/index.html
June 01, 2020 - The Federal Balanced Budget Act of 1997 mandated increased attention to performance monitoring as a tool … How do you build staff expertise in quality oversight and monitoring? … Without using quality measurement to assess the situation both before and after the changes designed
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/ap2.html
August 01, 2022 - I find giving him examples real life helps him think more deeply about the situation at hand. … Because of the difficulty and emotional intensity of the situation, the message avoids the main point … or minimizes the severity of the problem/difficult situation. … In a disclosure situation, most aspects of these messages involve managing the emotional response of … We called the code blue to have the quickest and best response to her situation.
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psnet.ahrq.gov/issue/awareness-and-use-cognitive-aid-anesthesiology
January 05, 2017 - August 21, 2019
Customer focused incident monitoring in anaesthesia.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/sppcii-hypertension-scenarios.pptx
July 01, 2023 - additional 10 mg of IV hydralazine (Apresoline).
12
Severe Hypertension
Master Case
13
Fetal monitoring … Alice Smith, the patient
Frontline
SPPC-II
SCRIPT
In the meantime, fetal monitoring remains reassuring … Johnson, obstetrician
Situation
Frontline
SPPC-II
SCRIPT
Kim, the triage nurse, calls Dr. … Beth begins with a summary of the patient’s situation, “Ms. … Johnson begins by describing the situation as she remembers it.
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psnet.ahrq.gov/node/35104/psn-pdf
April 06, 2011 - Using the first 4000 reports from the Australian Incident Monitoring Study (AIMS), a team of
anesthetists
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_safe-csection.docx
May 01, 2017 - decide its approach to debriefing events based on seriousness of event, expertise available, and data monitoring … Use SBAR (Situation, Background, Assessment, and Recommendation), callouts, huddles, and closed-loop … .
· E: Express how the situation makes you feel or concerns you.
· S: Suggest other alternatives.
· C … · Process for consent may vary by urgency of the clinical situation, but the patient and family are … Circulating nurse initiates ONLY if appropriate for the level of maternal/fetal distress and clinical situation
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integrationacademy.ahrq.gov/products/ibh-lexicon/practice-differences
July 01, 2024 - Teamwork
Clinical functions in place
Tailored to the needs of each patient and situation … factors play a role Accessible, easy-to-understand community resource connections Follow-up, outcome monitoring … stage of life, social or care complexity, racial or other identified minority group, or other specific situation … identify who especially needs it—either at the level of individuals or subpopulations (such as clinical situation … Referral, communication, and other processes are non-standard and vary with each clinician and clinical situation
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kleinpeter.pdf
January 01, 2004 - To determine the appropriate level of care for patients, perioperative
evaluations, monitoring and followup … In these situations, patients are accompanied by a nurse or
placed in a monitored situation in the specialized … After this initiative, the clinics performing procedures have adopted
regular monitoring and reporting … Regular reviews of activities, monitoring of
compliance with policies for ambulatory clinic
procedures … Ambulatory clinics require regular reviews of activities, including monitoring of
compliance with policies
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psnet.ahrq.gov/web-mm/chest-tube-complications
September 27, 2023 - ventilation, which increases the likelihood and risk of an air leak).( 11 ) During a clamp trial, close monitoring … this case include lack of clear guidelines on chest tube removal, such as assigning responsibility for monitoring … chest tube care path that outlines an algorithm for safe removal of chest tubes, including frequency of monitoring … September 25, 2019
Improving situation awareness to advance patient outcomes: a systematic
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs025238-xie-final-report-2020.pdf
January 01, 2020 - Instead, they search prior experience for
patterns to recognize a situation (pattern matching) and … In addition, we are monitoring the use of the electronic CDS tool
on the PICU at JHH and categorizing … (Ideal situation) Did antibiotics result in no sepsis
developed or did CDS tool and clinician
misdiagnose … CDS √
Clinician √
(Ideal situation) Why did sepsis develop after the
administration of antibiotics … Indicating other sources
of patient information
Recognizing
patient with
change of
status
• Monitoring
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psnet.ahrq.gov/node/72811/psn-pdf
September 01, 2022 - Version 2.0 incorporates dynamic ECG monitoring, imaging
display, videoconferencing facilities, and
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psnet.ahrq.gov/issue/2008-recommendations-pre-anesthesia-checkout-procedures
April 22, 2020 - , 2021
Root cause analysis using the prevention and recovery information system for monitoring … August 9, 2023
APSF endorsed statement on revising recommendations for patient monitoring
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Miller_93.pdf
March 12, 2008 - The
dispensing machines allow for systematic monitoring of access to controlled substances, auditing … The high
rates of complications in this situation suggest
a need for greater control of utilization … importance
of utilizing the electronic medication barcoding
technology, especially in the “override”
situation
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www.ahrq.gov/hai/cauti-tools/facil-guide/preventing-cauti-icu-setting-transcript.html
February 01, 2023 - care unit)
Anticipated large-volume infusions or diuretics during surgery
Need for intraoperative monitoring … It is important to first engage care providers and connect the situation directly to the impact on the … What elements of the situation led Sally to make her decision? … What might the manager do to mitigate this situation? … Slide 10
What might the manager do to mitigate this situation?
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digital.ahrq.gov/ahrq-funded-projects/nicu-2-home-using-health-it-support-parents-nicu-graduates-transitioning-home
January 01, 2023 - complicated home and outpatient care needs well into the first year of life, including home oxygen and monitoring … like themselves online; for instance, mothers looked for blogs written by other mothers in the same situation
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www.ahrq.gov/teamstepps-program/curriculum/team/overview/index.html
May 01, 2023 - Monitoring and Modifying the Plan
Huddle — Ad hoc meeting to ensure continual progression of care