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41. Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm. | PSNet
    psnet.ahrq.gov/issue/implementing-robust-process-improvement-program-neonatal-intensive-care-unit-reduce-harm
    March 23, 2022 - Implementing a robust process improvement program in the neonatal intensive care unit … Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm. … Medical errors in the neonatal intensive care unit threaten patient safety . … Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm. … From the Same Author(s) Frequency of diagnostic errors in the neonatal intensive care unit

42. Monitoring for Perinatal Safety: Electronic Fetal Monitoring | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/safe-electronic-tool.html
    July 01, 2023 - Who should use this tool: Nurses, physicians, midwives, and other labor and delivery (L&D) unit staff … determine how the elements will be implemented on your L&D unit. … Use of unit-established standing nurse orders Category III FHR tracings. … A unit-established process should: Specify patient, nurse, and unit criteria for use of IA. … Unit-established process for disclosing unintended outcomes.

43. Perinatal Safety Strategies | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies.html
    July 01, 2023 - Toolkit for Improving Perinatal Safety This pillar helps teams use concepts of the Comprehensive Unit-based … Safe Magnesium Sulfate Administration ( Word , 625 KB; Text Version ) General Labor and Delivery Unit … Safety Labor and Delivery Unit Safety: Slide Presentation ( PowerPoint , 1.32 MB; Text Version … ) Labor and Delivery Unit Safety: Facilitator Guide ( Word , 2 MB; PDF , 1.4 MB; Text Version )

44. Safe Medication Administration: Oxytocin | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/medication/tool-safe-oxytocin.html
    July 01, 2023 - The key elements are presented within the framework of the Comprehensive Unit-based Safety Program (CUSP … How to use this tool: Review the key perinatal safety elements with L&D leadership and unit staff to … determine how elements will be implemented on your L&D unit. … A sample of how some of these key perinatal safety elements can be incorporated into a unit approach … Use unit-established parameters for maternal and fetal monitoring at regular intervals.

45. Staff Safety Assessment | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/mvp/modules/cusp/staff-safety-asst.html
    January 01, 2017 - The purpose of this tool is to tap into frontline knowledge to find risks on your unit that impact patient … All health care providers and administrative staff on the unit should use this tool. … All health care providers on the unit should complete this tool at least twice a year. … you think the next patient in your unit/clinical area will be harmed? … Thank you for helping to improve safety on your unit.

46. Nudge Unit Supports Physician, Patient Behavioral Changes Towards Medical Decisions that Improve Care Value and Quality of Care | PSNet
    psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-medical-decisions
    July 23, 2024 - Nudge Unit Supports Physician, Patient Behavioral Changes Towards Medical Decisions that Improve Care … The Nudge Unit at Penn Medicine focuses on a range of different care improvement projects, including … A list of Nudge Unit projects can be found here: https://nudgeunit.upenn.edu/portfolio . … Funding Sources Funding for nudge projects under the Nudge Unit comes from Penn Medicine. … Key insights on launching a Nudge Unit within a health care system.

47. Staff Safety Assessment | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cusp/toolkit/staff-safety-assessment.html
    December 01, 2012 - Staff Safety Assessment CUSP Toolkit Determine what risks are present in your unit Purpose … into your experience at the front line of patient care to determine what risks are present in your unit … Drop off your completed assessment in the location designated by the unit team. … Name (optional): Job category: Date: Unit: Please describe how you think the next patient in … your unit or clinical area will be harmed.    

48. Operating room to intensive care unit handoffs and the risks of patient harm. | PSNet
    psnet.ahrq.gov/issue/operating-room-intensive-care-unit-handoffs-and-risks-patient-harm
    October 05, 2022 - Study Operating room to intensive care unit handoffs and the risks of patient harm … Operating room to intensive care unit handoffs and the risks of patient harm. … failure mode and effect analysis to study handoffs between the operating room and the intensive care unit … Operating room to intensive care unit handoffs and the risks of patient harm. … and hospital discharge diagnosis and its impact on length of stay, up-triage to the intensive care unit

49. Validity of unplanned admission to an intensive care unit as a measure of patient safety in surgical patients. | PSNet
    psnet.ahrq.gov/issue/validity-unplanned-admission-intensive-care-unit-measure-patient-safety-surgical-patients
    May 26, 2021 - Study Validity of unplanned admission to an intensive care unit as a measure of patient … Validity of unplanned admission to an intensive care unit as a measure of patient safety in surgical … to identify 200 patients who experienced an unplanned postoperative admission to an intensive care unit … Validity of unplanned admission to an intensive care unit as a measure of patient safety in surgical … September 12, 2016 Factors associated with post-intensive care unit adverse events: a

50. Accuracy and safety of medication histories obtained at the time of intensive care unit admission of delirious or mechanically ventilated patients. | PSNet
    psnet.ahrq.gov/issue/accuracy-and-safety-medication-histories-obtained-time-intensive-care-unit-admission
    October 20, 2021 - Accuracy and safety of medication histories obtained at the time of intensive care unit … Accuracy and safety of medication histories obtained at the time of intensive care unit admission of … When patients are admitted to the intensive care unit, medication histories can be obtained from alternate … Accuracy and safety of medication histories obtained at the time of intensive care unit admission of … Validation of the second victim experience and support tool-revised in the neonatal intensive care unit

51. Overview | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cauti-tools/guides/implguide-pt1.html
    October 01, 2015 - Intensive Care Unit Infographic Poster Appendix M. … practices and elimination of catheter-associated urinary tract infections (CAUTI) in your hospital unit … When used with the Comprehensive Unit-based Safety Program (CUSP) Toolkit, the practices outlined in … The Solution To achieve CAUTI reduction and sustain these improvements, a strategy to address both unit … Culture consists of the unit team’s values, attitudes, and beliefs, which will all have an impact on

52. Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle. | PSNet
    psnet.ahrq.gov/issue/reducing-rate-catheter-associated-bloodstream-infections-surgical-intensive-care-unit-using
    November 16, 2022 - Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit … Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using … line–associated bloodstream infections, preventing an estimated 2.5 deaths per year in this single unit … Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using … Reducing catheter-associated bloodstream infections in the pediatric intensive care unit

53. HSOPS | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cusp/clabsi-final-companion/clabsicomp5a.html
    January 01, 2013 - improvement was found in two dimensions: "feedback and communication about error" and "teamwork within unit … survey 13 designed to assess clinician and staff perceptions of the culture of safety within their unit … The instrument contains seven unit-level safety culture dimensions, four hospital-level dimensions, and … Participating units were invited to collect fresh HSOPS data from unit staff members or to upload previously … about error" (38.9 percent at baseline versus 44.8 percent at follow-up; p <0.01) and "teamwork within unit

54. Measurement | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cauti-tools/guides/implguide-pt4.html
    October 01, 2015 - Intensive Care Unit Infographic Poster Appendix M. … Trends The collection and reporting of data is an effective means of first engaging unit … Assess each patient on the unit for the presence of a urinary catheter, and record the indication for … CAUTI rate is one way to measure the outcomes of the care of patients’ urinary needs on your unit. … Post this metric in the nursing station of your unit or on a hallway bulletin board.

55. Electronic Health Record Solutions for Accurate Reporting of Data on Interprofessional Intensive Care Unit Rounds | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/electronic-health-record-solutions-accurate-reporting-data-interprofessional
    January 01, 2023 - Electronic Health Record Solutions for Accurate Reporting of Data on Interprofessional Intensive Care Unit … Description Publications The issue of communication errors during intensive care unit … Electronic Health Record/Electronic Medical Record Care Setting Intensive Care Unit … Electronic Health Record Solutions for Accurate Reporting of Data on Interprofessional Intensive Care Unit … Electronic Health Record Solutions for Accurate Reporting of Data on Interprofessional Intensive Care Unit

56. Prompting rounding teams to address a daily best practice checklist in a pediatric intensive care unit. | PSNet
    psnet.ahrq.gov/issue/prompting-rounding-teams-address-daily-best-practice-checklist-pediatric-intensive-care-unit
    June 30, 2021 - Prompting rounding teams to address a daily best practice checklist in a pediatric intensive care unit … Prompting rounding teams to address a daily best practice checklist in a pediatric intensive care unit … In a single institution's pediatric intensive care unit , a quality champion who prompted teams to discuss … Prompting rounding teams to address a daily best practice checklist in a pediatric intensive care unit … Impact of a drug shortage on medication errors and clinical outcomes in the pediatric intensive care unit

57. Sustainability Scorecard | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/mvp/sustainability/scorecard.html
    January 01, 2017 - Adaptive Work | Comprehensive Unit-based Safety Program (CUSP) Red Yellow Green What … 0 1 2 or more How many defects have you fixed on your unit within the last 6 months? … 0 1 2 or more How many CUSP meetings has your unit held in the last 6 months? … Mostly red: Your unit is below target at implementing interventions. … Mostly yellow: Your unit has been moderately successful at implementing interventions.

58. Culture Check-Up Tool | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cusp/toolkit/culture-checkup.html
    December 01, 2012 - Attitudes reflect the norms, values, and beliefs in the unit and, in turn, create the culture. … This tool can be used to target a goal for improvement in unit safety shortly after the initial culture … Remember, attitudes reflect the norms, values, and beliefs in the unit and, in turn, create the culture … This discussion can be informal, such as over a lunch break, or it can be a formal agenda item for unit … How accurately does the unit score reflect your experience on this unit?

59. Nurses' perception of medication administration errors and factors associated with their reporting in the neonatal intensive care unit. | PSNet
    psnet.ahrq.gov/issue/nurses-perception-medication-administration-errors-and-factors-associated-their-reporting
    December 14, 2022 - medication administration errors and factors associated with their reporting in the neonatal intensive care unit … medication administration errors and factors associated with their reporting in the neonatal intensive care unit … Medication administration errors (MAE) in the neonatal intensive care unit (NICU) are prevalent . … Prevalence, causes and severity of medication administration errors in the neonatal intensive care unit … The nurses' experience of barriers to safe practice in the neonatal intensive care unit

60. Caregiver Innovations to Reduce Harm in Neonatal Intensive Care | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/resources/learning-lab/caregiver-nicu-long-desc.html
    April 01, 2022 - learning focused on reducing all-cause preventable harm by 50 percent in the neonatal intensive care unit … developed causal-loop diagrams and a simulation model to help identify various individual-, team-, and unit … Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm … An ethnography of parents' perceptions of patient safety in the neonatal intensive care unit . … care unit.