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psnet.ahrq.gov/issue/medication-related-interventions-improve-medication-safety-and-patient-outcomes-transition
October 27, 2021 - Patients transferring from the intensive care unit (ICU) to the hospital ward may experience medication … Systematic review and meta-analysis of interventions for operating room to intensive care unit … Resources
Medication reconciliation for patients after their discharge from intensive care unit … An observational study of changes to long-term medication after admission to an intensive care unit
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www.ahrq.gov/hai/cusp/modules/spread/spread.html
December 01, 2012 - organization share, tailor, and implement the components of a process that have worked well at the unit … This module explores how to take the work from the unit level to the organization level. … Work With the Next Unit
Slide 13. Account for Variability
Slide 14. … Safety interventions targeted at the unit level (CUSP). … Work with the next unit to spread.
Account for variability.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/cauti-tools/cauti-icu/preventing-cauti-icu-setting-module_4-speaker-notes.docx
September 01, 2015 - modules on how to stop catheter-associated urinary tract infections, or CAUTI, in your intensive care unit … It highlighted the use of unit protocols related to catheter use. … Fight that urge and help your unit maintain its commitment to excellence. … Avoid overuse.
· -Observe what happens in your unit and how catheters are used. … .
· -Communicate with others from both inside and outside your unit.
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www.ahrq.gov/teamstepps-program/resources/videos/index.html
June 01, 2023 - TeamSTEPPS provides video simulation training for:
Team Leadership Unit (goes with module 2 curriculum … Situation Monitoring Unit (goes with module 3 curriculum ). … Mutual Support Unit (goes with module 4 curriculum ).
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digital.ahrq.gov/population/infants
January 01, 2023 - and monitor psychological symptoms in parents of infants hospitalized in the neonatal intensive care unit … Decision Support Optimizing Necrotizing Enterocolitis Prevention Implementation in Neonatal Intensive Care Unit … Decision Support Optimizing Necrotizing Enterocolitis Prevention Implementation in Neonatal Intensive Care Unit … Decision Support Optimizing Necrotizing Enterocolitis Prevention Implementation in Neonatal Intensive Care Unit … Decision Support Optimizing Necrotizing Enterocolitis Prevention Implementation in Neonatal Intensive Care Unit
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www.ahrq.gov/hai/cusp/clabsi-final-companion/clabsicomp3.html
January 01, 2013 - Unit Characteristics
The majority of registered units were adult ICUs although some adult non-ICUs … Further breakdown of unit type composition can be found in Figure 3 through Figure 5 .
Figure 2. … Percent of registered unit by unit type
Figure 3. Types of registered adult ICUs
Figure 4. … Variability was found when assessing data submission rates by unit classification with adult ICUs and
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/early-mobility-icu-slides.pptx
January 01, 2017 - Presentation: Program Overview
Early Mobility in the Intensive Care Unit
AHRQ Safety Program for Mechanically … Early intensive care unit mobility therapy in the treatment of acute respiratory failure. … Early intensive care unit mobility therapy in the treatment of acute respiratory failure. … Early intensive care unit mobility therapy in the treatment of acute respiratory failure. … Early intensive care unit mobility therapy in the treatment of acute respiratory failure.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxsamplereports.pdf
April 02, 2025 - • Quarterly Summary of Falls Risk Factors by Unit or Facility. … Sample Falls High-Risk Report
Unit: _______________________________________________________________ … by Unit
Nursing Unit: ___________________________________________________________
Date: ___/__ … Using the reports, teams will be able to:
• Identify trends and patterns by nursing unit and target … The report displays fall information for
a specific nursing unit or the entire facility trended for
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psnet.ahrq.gov/issue/validation-second-victim-experience-and-support-tool-revised-neonatal-intensive-care-unit
September 24, 2017 - Validation of the second victim experience and support tool-revised in the neonatal intensive care unit … Validation of the second victim experience and support tool-revised in the neonatal intensive care unit … Validation of the second victim experience and support tool-revised in the neonatal intensive care unit … Postdischarge adverse events among neonates admitted to the neonatal intensive care unit … Prevalence, causes and severity of medication administration errors in the neonatal intensive care unit
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/ipe-large-org-webcast-fishkin.pdf
March 24, 2020 - Practice Workflow: Unit Arrival
20 | Copyright © 2020 Kaiser Foundation Health Plan, Inc. … Patient
Experience Patient
arrives on
unit
Patient sees “Ask 3”
Document posted on
wall with … contains medication
sheet
RN reviews “Ask 3”
concept and
purpose of
medication sheet
Key
Enablers
Unit … to team in English and other preferred languages
Maternity Care: upon patient arrival in maternity, unit … Case Study: Medication Communication Composite
Processes for Quality Improvement
Practice Workflow: Unit
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/leveraging-cultural-change-080814.pptx
January 01, 2013 - MPS,CIC
Manager Infection Prevention
Highland Hospital
Jennifer Tuttle, RN, MSNEd
Adult Critical Care Unit … Polling Question #1
What is your background:
State Lead
CUSP Faculty
Fellow or Mentor for CAUTI project
Unit … Physician Resistance
Nursing Resistance
Real or perceived need for accurate I and O
Unit culture which … Communication- standardized processes and metrics
Local focused implementation – implementation at unit … This varies from unit to unit.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/infectionprevchcklst.doc
April 02, 2025 - Work with
unit teams to investigate each incident and report the findings across the institution. … Provide monthly
unit-level
data to project leads for posting and transparent … Send senior hospital leaders unit-specific weekly reports on the number of people infected with
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psnet.ahrq.gov/issue/clinical-practice-guideline-safe-medication-use-icu
February 19, 2014 - Patients in the intensive care unit (ICU) may be particularly vulnerable to medication errors due to … laboratory abnormalities on identifying potentially preventable adverse drug events in the intensive care unit … April 24, 2018
Multiprofessional survey of protocol use in the intensive care unit. … automated surveillance system using trigger alerts to prevent adverse drug events in the intensive care unit … 2010
Adverse-drug-event rates for high-cost and high-use drugs in the intensive care unit
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psnet.ahrq.gov/node/46123/psn-pdf
January 01, 2020 - Improving patient safety in handover from intensive care
unit to general ward: a systematic review. … Improving Patient Safety in Handover From Intensive Care Unit to General Ward: A
Systematic Review. … https://psnet.ahrq.gov/issue/improving-patient-safety-handover-intensive-care-unit-general-ward-
systematic-review … https://psnet.ahrq.gov/issue/improving-patient-safety-handover-intensive-care-unit-general-ward-systematic-review … handoffs-and-signouts
https://psnet.ahrq.gov/issue/look-nature-and-causes-human-errors-intensive-care-unit
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/167-hospital-level-gap-analysis.pdf
April 02, 2025 - Is an infection preventionist assigned to each intensive care unit (ICU) in the hospital? … Is an infection preventionist assigned to each non-intensive care unit (non-ICU) in the hospital? … How often does the infection preventionist visit their unit(s) routinely? … Secret observations by unit staff
Secret observations by individual(s) not from the unit
… Ongoing observations on the units
Unit self-assessments
Periodic observation assessments
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/forming-cuspteam-facguide.docx
January 01, 2017 - Bundle
Slide Title and Commentary
Slide Number and Slide
Title Slide
Forming a Comprehensive Unit-based … Safety Program Team
SAY:
Today, we will briefly revisit the key concepts of the Comprehensive Unit-based … Slide 10
Team Roles—Unit Manager
SAY:
The unit manager is often either a nurse manager or unit manager … The unit manager mentors the team to speak up and identify defects. … Third, use unit-level data and staff inputs to drive improvement efforts.
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www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/teamwork-ptsafety-norms-slides.pdf
March 18, 2025 - the understanding that all culture is local
and that work to improve culture must be owned at
the unit … Implementation
• Developed multidisciplinary team
► Included all 3 ICUs, medical directors of each unit … response to “how will the next patient
be harmed”
► Rolled out house-wide with expectation
that each unit … Improving teamwork: Impact of structured interdisciplinary rounds on a medical teaching unit. … done in ICUs and all units in hospital
• Hard initiative to implement, especially if you have an open unit
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www.ahrq.gov/news/newsroom/case-studies/ktcquips50.html
October 01, 2014 - Hubbell and her colleagues made presentations to each unit or department that participated in the AHRQ … Hubbell and her colleagues then led discussions with each unit about ways to improve performance. … These discussions served as the basis for developing action plans for each unit, which were finalized … According to Hubbell, the telemetry unit was one of the units that did not have high scores on the survey … improve performance, the organizational development department was tasked with assisting the telemetry unit
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/05-sops-teamstepps-webcast-mazur.pdf
April 30, 2022 - reality training)
26
Agenda
Longitudinal analysis of SOPS scores
Cross-sectional analysis of unit-based … data only)
Communication about error 82 +15
We are informed about errors that happen in this unit. … 80 +15
When errors happen in this unit, we discuss ways to
prevent them from happening again. 84 + … 14
In this unit, we are informed about changes that are
made based on event reports. 82 +16
TENTS … At the unit level: Identify positive and negative aspects of culture
of patient safety and relate them
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psnet.ahrq.gov/web-mm/what-happened-telemetry
January 18, 2012 - Because of her history of CHF, she was admitted to a unit with telemetry monitoring. … When the patient arrived on the telemetry unit, the nurse performed a full evaluation. … He tried to call back the unit and no one answered. … The remote telemetry monitoring technician's phone call to the unit went unanswered. … telemetry box would provide essential information on the unit.
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