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psnet.ahrq.gov/issue/appropriateness-commercially-available-and-partially-customized-medication-dosing-alerts
July 16, 2015 - July 29, 2020
Perceptions of rounding checklists in the intensive care unit: a qualitative … range checking using hard and soft stop alerts reduces prescribing errors in a pediatric intensive care unit
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psnet.ahrq.gov/issue/benefactor-or-burden-exploring-professional-identity-safety-professionals
October 11, 2017 - June 13, 2018
Structured interdisciplinary rounds in a medical teaching unit: improving … 2011
Educational strategy to reduce medication errors in a neonatal intensive care unit
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psnet.ahrq.gov/issue/crying-wolf-alarm-safety-and-management-paediatrics-scoping-review
April 24, 2018 - range checking using hard and soft stop alerts reduces prescribing errors in a pediatric intensive care unit … Improving safety throughout the medication use process in a neonatal intensive care unit
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psnet.ahrq.gov/node/49831/psn-pdf
June 01, 2018 - this medication error did not surface until
2 hours later when the patient arrived in the acute care unit … Delays from the admission decision to arrival
on the inpatient unit are problematic. … The median time from ED provider decision to admit to patient arrival
on the inpatient unit in the US … off-site
internist) had responsibility for this patient before he was transferred to the inpatient unit … of
delayed transfer of critically ill patients from the emergency department to the intensive care unit
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psnet.ahrq.gov/issue/explaining-michigan-developing-ex-post-theory-quality-improvement-program
April 04, 2011 - Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit … Reducing catheter-associated bloodstream infections in the pediatric intensive care unit
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psnet.ahrq.gov/issue/uncovering-system-errors-using-rapid-response-team-cross-coverage-caught-crossfire
April 24, 2018 - September 12, 2016
Unplanned transfers to a medical intensive care unit: causes and relationship … A 5-year analysis of rapid response system activation at an in-hospital haemodialysis unit
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psnet.ahrq.gov/issue/resilience-nursing-medication-administration-practice-systematic-review-narrative-synthesis
February 18, 2017 - interventions to reduce the frequency of critical medication doses missed or delayed during perioperative and unit-to-unit
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psnet.ahrq.gov/web-mm/cups-error
January 12, 2011 - During his stay at a rehabilitation unit, a nursing student administered a “cup” of medications that … Unfortunately, this cup of medications belonged to another patient on the unit. … On this particular unit, nursing students receive supervision from a senior nursing instructor. … administration record (MAR) should be taken by the nurse to the bedside, and medications should remain in the unit-dose–labeled
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psnet.ahrq.gov/issue/effects-interdisciplinary-team-care-interventions-general-medical-wards-systematic-review
April 24, 2018 - March 16, 2016
Communication skills and error in the intensive care unit. … April 28, 2010
Developing a team performance framework for the intensive care unit.
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psnet.ahrq.gov/issue/economic-evaluation-quality-improvement-interventions-prevent-catheter-associated-urinary
January 25, 2017 - Systematic review and meta-analysis of interventions for operating room to intensive care unit … , 2022
Reducing three infections across cardiac surgery programs: a multisite cross-unit
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psnet.ahrq.gov/issue/physician-attitudes-toward-family-activated-medical-emergency-teams-hospitalized-children
April 06, 2012 - between mobile telephone interruptions and medication administration errors in a pediatric intensive care unit … resource management and a 'read-and-do checklist' to reduce failure-to-rescue events on a step-down unit
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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/issue/failure-engage-hospitalized-elderly-patients-and-their-families-advance-care-planning
November 21, 2016 - November 28, 2016
Family participation during intensive care unit rounds: goals and expectations … of parents and health care providers in a tertiary pediatric intensive care unit.
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psnet.ahrq.gov/issue/high-prevalence-medication-discrepancies-between-home-health-referrals-and-centers-medicare
December 23, 2011 - Discontinuity of chronic medications in patients discharged from the intensive care unit … An observational study of changes to long-term medication after admission to an intensive care unit
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psnet.ahrq.gov/innovation/preventing-falls-through-patient-and-family-engagement-create-customized-prevention
July 23, 2024 - provider teams) willing and able to work together
Support and buy-in from nursing staff and hospital and unit … program includes assessing the patient’s knowledge of their risk factors and prevention plan at the unit … provider teams) willing and able to work together
Support and buy-in from nursing staff and hospital and unit … More specifically,nurses should have channels to provide ongoing feedback to both staff and unit leadership
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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.
-
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/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