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Showing results for "follow up".

3421. Aviation Safety Methods: Quickly Adopted but Questions Remain | PSNet
      psnet.ahrq.gov/perspective/aviation-safety-methods-quickly-adopted-questions-remain
      January 01, 2006 - JB: That question—of "fixed" versus "formed" teams—comes up in both aviation and health care. … Whereas, in the formed crews, those that are just put together for the mission, they tend to follow the … You have the pilot, co-pilot, and flight engineer—all of them are professional people relatively high up … had another incident where one team member present during a surgery felt empowered to actually speak up … The individual who spoke up never would have said anything prior to the training.

3422. In Conversation with Lucy Savitz about Learning Health Systems for Patient Safety | PSNet
      psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learning-health-systems-patient-safety
      February 26, 2025 - One clinical program starts, and then others in the organization may see that it’s a good idea and follow … across the 16 delivery systems and answer the question: No, you are not harming your patients if you follow … Savitz: Run charts and statistical process control charts are probably most effective because you can follow … If it goes up, you have not. … As we transfer care from hospital-based to ambulatory to home-based, the people who end up in the hospital

3423. Learning Health Systems for Patient Safety | PSNet
      psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
      February 26, 2025 - One clinical program starts, and then others in the organization may see that it’s a good idea and follow … across the 16 delivery systems and answer the question: No, you are not harming your patients if you follow … Savitz: Run charts and statistical process control charts are probably most effective because you can follow … If it goes up, you have not. … As we transfer care from hospital-based to ambulatory to home-based, the people who end up in the hospital

3424. The Safety of Medical Devices | PSNet
      psnet.ahrq.gov/perspective/safety-medical-devices
      June 01, 2011 - ET : I like the idea of checklists up to a point. … me uneasy about the checklists is the assumption that there is a body of best practices and you just follow … Everybody else in an organization will tend to follow the lead of the CEO.

3425. Diagnostic Errors | PSNet
      psnet.ahrq.gov/perspective/diagnostic-errors
      December 01, 2013 - advantages of straddling the research and operational line, which is if you can do this work well, it opens up … safety issues were built nicely on our previous sociotechnical approaches to understanding and improving follow-up … having the confidence that if you care, it's an important issue and the world will eventually catch up … Revelation March 1, 2004 WebM&M Cases Patient Mix-Up

3426. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33701/psn-pdf
      October 01, 2010 - activities surrounding the insertion of central venous catheters that reduced bloodstream infections up … to allocate tasks to individuals.(13) This prevents diffusion of responsibility (i.e., no one ends up

3427. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49427/psn-pdf
      January 01, 2004 - have the capacity to efficiently orient team members to the task at hand and enable them to "speak up … Mandatory team briefings, with invitations by the team leader for participants to step back and speak up

3428. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866846/psn-pdf
      September 24, 2024 - notes that, since the 2013 launch of their Certified Zero Harm Awards, member hospitals have achieved up … Will health systems free up resources as harms become less frequent, or will efforts to reach zero harm

3429. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49782/psn-pdf
      January 01, 2017 - It was started at a low dose but then titrated up to 20 ? … Association of Emergency Physicians endorses the use of peripheral vasopressor administration for up

3430. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49572/psn-pdf
      October 01, 2008 - increasingly uncomfortable with the conversation, the patient in the neighboring bed finally spoke up … Patients with the same (or similar) names are often found within most health care systems, with up to

3431. Medication Handling and Compounding Errors in the Operating Room. | PSNet
      psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
      May 16, 2022 - The scrub technician draws up the medication in a syringe and places the label on the syringe. … Regardless of the state this case occurred in, emphasis must be placed on the need for surgical teams to follow … Compounded medications should follow USP <797> standards on sterility, handling/storage, and beyond use

3432. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846126/psn-pdf
      March 09, 2023 - The scrub technician draws up the medication in a syringe and places the label on the syringe. … Regardless of the state this case occurred in, emphasis must be placed on the need for surgical teams to follow … Compounded medications should follow USP <797> standards on sterility, handling/storage, and beyond

3433. Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome | PSNet
      psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negative
      April 27, 2022 - This requires clinicians to lower the testing threshold and follow evidence-based recommendations for … If these markers are normal, other diagnoses should be considered and discharge with follow-up may be … More Related Resources WebM&M Cases Coming up

3434. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_case_mesenteric_ischemia_08.05.2022.pdf
      January 01, 2022 - • Explain how the differential diagnosis and work-up of acute abdominal pain differs between people … • None of these physicians followed up on the possibility of mesenteric ischemia, reportedly because

3435. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49771/psn-pdf
      July 01, 2016 - She presented with sepsis and acute kidney injury with a creatinine of 2.0 mg/dL (up from a baseline … introduction of new technologies in other spheres—some paths to failure are closed off, but new ones open up … references https://psnet.ahrq.gov//#references https://psnet.ahrq.gov//#references User interfaces should follow

3436. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841305/psn-pdf
      January 27, 2023 - There are some basic principles that you follow, but there will also be some variation, and something … Sarah Mossburg: Yes, and that builds the capacity for resilience and sets up the groundwork for that. … by the opportunity to solve problems, by the autonomy, by the creative solutions they were coming up

3437. Don't Use That Port: Insert a PICC | PSNet
      psnet.ahrq.gov/web-mm/dont-use-port-insert-picc
      December 22, 2018 - WebM&M Cases Procedure Complications – Who is Responsible for Follow … up?

3438. Clinical Areas | PSNet
      psnet.ahrq.gov/clinical-areas
      March 24, 2025 - wide variation between the sites in referral processing, patient coordination, team communication, and follow … up.

3439. Check the Wristband | PSNet
      psnet.ahrq.gov/web-mm/check-wristband
      August 03, 2009 - I picked up the chart that was next to this patient. The chart was correct for my next patient. … anesthetist checked the patient's wristband and alerted the nurse to her error—the chart the RN had picked up … However, if all that results is a single individual vowing never to slip up again, the system will remain

3440. Thin Air | PSNet
      psnet.ahrq.gov/web-mm/thin-air
      March 01, 2006 - In this case, it seems that both the high-flow oxygen mask and the self-inflating bag were hooked up … "( 3 ) Much of the gas delivery system is designed to avoid hooking up the wrong gas hose to a compressed … end of an anesthetic, the anesthesiologist might reach back to turn off the nitrous oxide and turn up