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Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency | PSNet

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May 01, 2018 - Cardiology was consulted and recommended to transfer the patient to the cardiac intensive care unit ( … For a patient with only one “ICU level need” (i.e., a titratable infusion), a stepdown unit may have … Admission to a cardiac stepdown or critical care unit would have allowed more active blood pressure management … Was the overnight nursing supervisor or the charge nurse on the receiving unit empowered to raise questions

Good Night's Sleep Gone Wrong | PSNet

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September 01, 2015 - She was transferred to the hemodialysis unit where she underwent hemodialysis and was then admitted to … The patient was transferred to the medical intensive care unit for close observation and hemodialysis … August 20, 2018 Effect of work-hours regulations on intensive care unit mortality in

Handoff Communication. | PSNet

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October 16, 2019 - checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit

Center for Innovations in Quality, Effectiveness and Safety. IQuESt! | PSNet

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April 06, 2022 - Prompting rounding teams to address a daily best practice checklist in a pediatric intensive care unit

Patient Safety Essentials Toolkit. | PSNet

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January 08, 2020 - December 27, 2014 Unit-based care teams and the frequency and quality of physician–nurse

Operationalizing Patient Safety at Academic Medical Centers | PSNet

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August 01, 2010 - Richard Shannon : At Penn, we picked four medicine units: the medical intensive care unit and three … But the 26-bed unit in Pittsburgh where we did this effort has now gone 35 months without a central line … results—every member of this team gets a daily report on whether or not there's an infection on their unit—begins … across what we call the customer–supplier relationship between the cath lab and our inpatient medicine unit … Allergy August 31, 2022 Effect of work-hours regulations on intensive care unit

Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough | PSNet

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September 01, 2003 - At the handoff to the post-anesthesia care unit (PACU) nurse, the OR nurse stated that there was packing … If care providers wait to tell the patient until after the ward or unit nurse receives another handoff … Thus , the receiving nurse should not delegate the responsibility to the ward or unit nurse (tertiary … Nurses may need additional training to perform digital vaginal exams, particularly if they are on a unit … Partnered pharmacist charting on admission in the general medical and emergency short-stay unit—a

An Inadvertent Bolus of Norepinephrine. | PSNet

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December 04, 2016 - The next day, the patient's blood pressure stabilized, and she was transferred to a stepdown unit, and … Doroy, PhD, RN, NEA-BC, RN-BC Nurse Manager, Medical Intensive Care Unit UC Davis Health Ai Nhat Vu PharmD … Errors in preparation and administration of intravenous medications in the intensive care unit of a teaching … Medication errors involving continuously infused medications in a surgical intensive care unit. … Unwritten rules for safety and performance in an oncology day care unit: Testing the resilience markers

Antimicrobial Stewardship. | PSNet

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October 24, 2018 - June 16, 2019 Infection Control in the Intensive Care Unit.

Another Fall | PSNet

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June 01, 2010 - The patient showed continued improvement and was transferred from the ICU to the step-down unit. … patient’s repeat fall: the floor nurses were not aware of the patient’s previous fall in the step-down unit … impairment, weight-bearing limitations, allergies, and falls history, etc.) to be transmitted from unit … to unit or provider to provider.

Preventing PICC Complications: Whose Line Is It? | PSNet

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October 01, 2017 - Quality (AHRQ), infections were reduced by 40% with application of the bundle through a comprehensive unit-based … Triple-lumen peripherally inserted central catheter in patients in the critical care unit: prospective … education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit

Where's the Feeding Tube? | PSNet

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September 01, 2003 - After many weeks in the intensive care unit (ICU), he was transferred to a rehabilitation unit with improved … prefer to start with small-bowel feedings in patients at high risk for aspiration, especially when unit

“This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event | PSNet

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July 01, 2017 - container before the person who obtained the sample leaves the bedside. 5.12 The ABO group of each donor unit … blood cell units. 5.14.5 The recipient’s historical records for ABO group are reviewed before every unit … issued. 5.23 At the time a unit is issued, two people verify the recipient ABO group and the donor ABO … red blood cell transfusion could therefore be estimated at 1-4 per 10,000,000 for each red blood cell unit

A Pill Organizing Plight | PSNet

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June 19, 2018 - readmission rates and a 90% reduction in medication-related readmissions on a geriatric special care unit … Medication access interventions, including unit dose packaging, have demonstrated an increase in medication … Geriatric pharmacy pilot's effect on reducing 30-day readmission rates on a geriatric special care unit … Unit dose calendar packaging and elderly patient compliance. N Z Med J. 1991;104:495-497.

Interruptions and multitasking in nursing care. | PSNet

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September 28, 2010 - September 27, 2017 Improving nursing unit teamwork.

Another tragic parenteral nutrition compounding error. | PSNet

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June 10, 2018 - April 14, 2010 Patient safety and quality in the pediatric intensive care unit.

Safe intrahospital transport of the non-ICU patient using standardized handoff communication. | PSNet

psnet.ahrq.gov/issue/safe-intrahospital-transport-non-icu-patient-using-standardized-handoff-communication

March 18, 2010 - December 31, 2014 Structured interdisciplinary rounds in a medical teaching unit: improving

ALERT: reports of severe harm after intravenous administration of breast milk to infants. | PSNet

psnet.ahrq.gov/issue/alert-reports-severe-harm-after-intravenous-administration-breast-milk-infants

May 02, 2018 - smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit

ISMP Targeted Medication Safety Best Practices for Community Pharmacy. | PSNet

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March 21, 2012 - Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia care unit

On the Other Hand | PSNet

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December 12, 2012 - The patient was admitted at 6:00 p.m. to the intensive care unit (ICU) for monitoring, pain medication … A look into the nature and causes of human errors in the intensive care unit. … Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American

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