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psnet.ahrq.gov/web-mm/unfamiliar-catheter
November 01, 2006 - The patient spent the next 3 days in the intensive care unit (ICU). … errors is high because medical device technology continually evolves and because nurses move from one unit … National survey of central venous catheter flushing in the intensive care unit. … Human factors analysis of latent safety threats in a pediatric critical care unit … An analysis of near misses identified by anesthesia providers in the intensive care unit
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psnet.ahrq.gov/node/49759/psn-pdf
May 01, 2016 - She
was placed on a mechanical ventilator and admitted to the intensive care unit. … The patient in this case was in an intensive care unit (ICU) at the time of the event. … Eliminating catheter-related bloodstream infections in
the intensive care unit. … Unit-level time trends in inpatient fall rates of US hospitals. Med Care.
2012;50:801-807. … A retrospective analysis of determinants of
self-extubation in a tertiary care intensive care unit.
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psnet.ahrq.gov/web-mm/40-k
January 12, 2011 - The unit nurse contacted the physician, who was engaged in a sterile procedure in the cardiac catheterization … laboratory (cath lab) and gave a verbal order, which was relayed to the unit nurse via the procedure … The unit nurse (whose past clinical experience was in neonatal intensive care) wrote the order as "Give … However, the unit nurse had already obtained vitamin K on override from the Pyxis MedStation® (an automated
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psnet.ahrq.gov/perspective/conversation-patricia-dykes-about-ongoing-journey-prevent-patient-falls
December 18, 2024 - There must be champions helping nurses understand and implement the evidence, identify unit-specific … In our clinical trial, we found that when patients on a nursing unit did not know their risk factors … Because of the Magnet Program, many hospitals have unit-based councils. … It is good to have nurses who have experience and are well-respected on the unit serve as champions. … We did a case control study and found the most common reason patients on the intervention unit fell in
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psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls
December 18, 2024 - One study examined the association between nursing unit safety culture, quality of care, nurse staffing … There must be champions helping nurses understand and implement the evidence, identify unit-specific … In our clinical trial, we found that when patients on a nursing unit did not know their risk factors … Because of the Magnet Program, many hospitals have unit-based councils. … It is good to have nurses who have experience and are well-respected on the unit serve as champions.
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psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
February 19, 2020 - She was placed on a mechanical ventilator and admitted to the intensive care unit. … The patient in this case was in an intensive care unit (ICU) at the time of the event. … Eliminating catheter-related bloodstream infections in the intensive care unit. … Unit-level time trends in inpatient fall rates of US hospitals. Med Care. 2012;50:801-807. … A retrospective analysis of determinants of self-extubation in a tertiary care intensive care unit.
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psnet.ahrq.gov/node/867986/psn-pdf
March 24, 2025 - If they
are in an emergency department, an inpatient unit, or, of course, a behavioral health unit, … high risk, safety
precautions need to be maintained, and they need to be admitted to a psychiatric unit … Edwin Boudreaux: In a medical unit, most beds or rooms have a lot of items that are unsafe for a person … Those are the
precautions you would take if a person were highly suicidal in a medical unit; do your … of the safety plan so that it's not just a piece of
paper or an exercise they did in the inpatient unit
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psnet.ahrq.gov/node/33559/psn-pdf
December 15, 2024 - their existing medications at times of
transitions in care—upon hospital admission, transfer from one unit … hospital admission, in-hospital transitions of care (such as
transfer into or out of the intensive care unit
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psnet.ahrq.gov/node/867759/psn-pdf
March 12, 2025 - psnet.ahrq.gov/issue/systematic-review-and-meta-analysis-interventions-operating-room-intensive-care-unit-handoffs
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psnet.ahrq.gov/node/867700/psn-pdf
March 01, 2023 - Designed to be used alongside the Comprehensive Unit-based Safety Program (CUSP) toolkit, this AHRQ
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psnet.ahrq.gov/perspective/burnout-among-health-professionals-and-its-effect-patient-safety
December 22, 2018 - and physicians on 54 ICU teams from 48 different hospitals, evaluated the effect of individual and unit-level … Importantly, the study controlled for unit workload and workload predictability. … When measured at the unit level, emotional exhaustion (a component of the overall burnout score) was
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psnet.ahrq.gov/node/73416/psn-pdf
June 23, 2021 - observational-study-postoperative-handoff-standardization-failures
Standardized handoff protocols from the operating room to the intensive care unit
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psnet.ahrq.gov/node/838133/psn-pdf
January 01, 2023 - leadership-style-and-patient-safety-implications-nurse-managers
https://psnet.ahrq.gov/issue/do-leadership-style-unit-climate-and-safety-climate-contribute-safe-medication-practices
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psnet.ahrq.gov/node/867701/psn-pdf
August 01, 2017 - This toolkit was
developed to help staff in intensive care units use AHRQ’s Comprehensive Unit-based
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psnet.ahrq.gov/web-mm/dont-push
March 02, 2011 - In the cardiac intensive care unit, she required placement of a transvenous pacemaker. … Practice parameters for intravenous analgesia and sedation for adult patients in the intensive care unit … Rapid tranquilization of the agitated intensive care unit patients. … Trends in central line–associated bloodstream infections in a trauma-surgical intensive care unit
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psnet.ahrq.gov/node/41861/psn-pdf
September 27, 2017 - according to this retrospective analysis of patients admitted to a Taiwanese surgical intensive care unit
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psnet.ahrq.gov/perspective/conversation-nicholas-g-castle-mha-phd
August 01, 2012 - did find the lowest scores in areas of the survey that reflect staffing issues and transition between unit … What we'd really like to do is look at the patient safety culture of a particular unit and the outcomes … RW : Brian Sexton's work shows that the differences in culture from unit to unit in hospitals are greater … Is your sense that there are a lot of differences unit to unit in nursing homes as well? … There may be directors of each unit, but compared with the hospital setting, there is not a hierarchy
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psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety
September 01, 2008 - Drug libraries may be unit specific, with unique rules for individual clinical areas such as pediatrics … 11 ) An obstacle to universal dissemination of BCMA is the lag in availability of bar-coded single-unit … which requires some institutions to repackage and bar code those drugs not yet available in the single-unit … With this technology, the nurse will not have to hunt around the unit looking for the paper medication … So when we rolled out barcode technology, we decided to not roll it out on the oncology unit, in order
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psnet.ahrq.gov/web-mm/check-wristband
August 03, 2009 - was reported to AHRQ WebM&M by this circulating nurse, who noted, “I went to the surgical day care unit … I had to take the patient off the OR table and return her to the surgical day care unit.” … Here, it would have been useful for the RN, the nurse anesthetist, and the unit clerk to meet and work … out a unit reminder system.
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psnet.ahrq.gov/web-mm/pca-overdose
April 01, 2017 - She remained alert and oriented and, while in the post-anesthesia care unit (PACU), she began receiving … nursing staff called a “code” and the patient was resuscitated and transferred to the intensive care unit … Thrombosis
June 28, 2023
Interdisciplinary communication in the intensive care unit