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Showing results for "how to do a case study".

2281. Microsoft PowerPoint - FINAL Spotlight Case_A Complicated Course-Severe Alcohol Withdrawal - SLIDES.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-07/spotlight_a_complicated_course.pdf
      January 01, 2023 - • Articulate how to minimize clinician bias in assessment of substance use disorders. 3 A COMPLICATED … in this case was admitted to a stepdown unit. … These medications control autonomic hyperactivity and decrease sympathetic activation; however, they do … • Free text communication is a type of order that providers can use to instruct nurses about how … Medication errors room: a simulation to assess the medical, nursing and pharmacy staffs’ ability to

2282. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization | PSNet
      psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
      September 01, 2012 - The Case A patient was referred to a cardiologist for elective diagnostic cardiac catheterization for … rare, with only case reports published. 10,11 Unfortunately, in this case, the complication was compounded … If needed, a pericardial drain could have been placed as a bridge to definitive surgical repair. … Any discussion of a catastrophic complication of this type is incomplete without exploring how communication … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not

2283. In Conversation With… J. Bryan Sexton, PhD, MA | PSNet
      psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma
      February 26, 2025 - How do you approach that? … how to do this teamwork stuff and then we're all going to be in this, holding hands in the hot tub, … quickly learn how to do things that get your employee engagement scores up. … How do you interpret the work on checklists? … I wanted to look at how we do quality a little differently.

2284. Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis | PSNet
      psnet.ahrq.gov/innovation/remote-response-team-and-customized-alert-settings-help-improve-management-sepsis
      February 26, 2025 - sustainable process to enhance their hospitals’ response to sepsis, a multidisciplinary team at WellSpan … To test the idea of a remote monitoring team, WellSpan established a small, 24-hour team of remote nurses … should do the following: Create evidenced-based protocols for implementing sepsis bundle elements … CATalyst for change: how members of WellSpan’s Central Alert Team (CAT) are revolutionizing sepsis care … CATalyst for change: how members of WellSpan’s Central Alert Team (CAT) are revolutionizing sepsis care

2285. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846769/psn-pdf
      March 29, 2023 - Her leukocyte count was elevated to 18,000/mm3 with a normal differential. … also occur in patients who are receiving treatment for AI if they miss their daily medications or do … Most adolescents presenting with fatigue do not have adrenal insufficiency. … A low threshold for outreach to a subspecialist in endocrinology. … Although many communities do not have local access to an endocrinologist, academic medical centers in

2286. Retained Surgical Items: Definition and Epidemiology. | PSNet
      psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
      September 15, 2024 - These soft goods are usually applied at the end of a procedure to cover or provide hemostasis in a wound … They do not contain radiopaque markers, are not to be placed inside patients, and are not counted. … to have experienced a “ never event ”, a safety event that is never supposed to happen. … Part 3 of the above definition is particularly important because of how surgical counts are performed … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not

2287. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837324/psn-pdf
      July 08, 2022 - In the case of promoting vaginal birth, it is important to understand how C-section rates impact maternal … Identify data to be collected, how it will be captured, by whom, and how often. … What We Do. https://www.cmqcc.org/about-cmqcc/what- we-do. Accessed March 3, 2022. … /what-we-do https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health … How much does it cost to give birth in the United States? It depends on the state. 

2288. In Conversation With... Jack Westfall, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-jack-westfall-md-mph
      September 28, 2022 - JW: How do we measure high quality? … The issue is, as a family doctor, I wasn’t trained in how to write code for the EHR to create a registry … We are always thinking about how to ensure that anything we do for patients may help them and decrease … How do we make sure we do that? … So how do we develop a taxonomy for patient safety, and how do we improve safe discussions around patient

2289. Burnout | PSNet
      psnet.ahrq.gov/primer/burnout
      November 20, 2024 - There appears to be a need for prospective studies to better understand the directionality of the relationship … stark reminder of how system failures can contribute to burnout. … Stigma Compounds the Consequences of Clinician Burnout During COVID-19: a Call to Action to Break the … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not … August 17, 2022 How does the environment influence consumers' perceptions of safety in

2290. Baffled by Botulinum Toxin | PSNet
      psnet.ahrq.gov/web-mm/baffled-botulinum-toxin
      July 17, 2024 - understand how this error occurred. … Standardizing how procedures and medication administration are documented is a reasonable step and should … [go to PubMed] 5. Partikian A, Mitchell WG. … Iatrogenic botulism due to therapeutic botulinum toxin A injection in a pediatric patient. … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not

2291. Failure to Latch | PSNet
      psnet.ahrq.gov/web-mm/failure-latch
      November 27, 2012 - Breastfeeding continued to be difficult, and the parents scheduled a face-to-face visit with the lactation … documented physicians' lack of knowledge about breastfeeding.( 4 ) The presented case demonstrates how … Such a meeting would have facilitated the development of a plan to ensure adequate infant intake while … Any intervention to increase infant intake should include a plan to protect or increase maternal milk … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not

2292. Never Events | PSNet
      psnet.ahrq.gov/primer/never-events
      June 15, 2024 - ulcers acquired after admission/presentation to a healthcare setting Artificial insemination with the … gas to be delivered to a patient contains no gas, the wrong gas, or is contaminated by toxic substances … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not … July 24, 2024 Identifying a list of healthcare 'never events' to effect system change: a systematic … July 12, 2023 How can never event data be used to reflect or improve hospital safety

2293. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61078/psn-pdf
      October 28, 2020 - Authors, reviewers and others in a position to control the content of this activity are required to … how CGM use alters routine care.  … Hospitals do not typically stock pump or CGM supplies11, and thus the patient should be responsible … If a patient has an immediate need for a particular supply item (i.e. due to a bad site or broken reservoir … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not

2294. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865412/psn-pdf
      March 27, 2024 - Authors, reviewers and others in a position to control the content of this activity are required to … The nurse practitioner managing the patient was uncertain as to whether the psychosis was due to a “ … a maladaptive emotional reaction to the diagnosis, rather than to CNS manifestations of SLE itself. … lesions and hematologic abnormalities appearing later.3 The diagnostic challenge remains regarding how … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not

2295. Around the Block | PSNet
      psnet.ahrq.gov/web-mm/around-block
      March 04, 2020 - The Case A 77-year-old woman with multiple medical problems was admitted to the hospital for an elective … A nurse and pharmacist had countersigned the signature block next to this warning. … And, perhaps most importantly, how did this series of events occur despite the presence of the warning … If he did not, how could this happen? … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not

2296. Microsoft PowerPoint - FINAL Spotlight Case_Medication Error During Procedural Sedation in the Pediatric ED_03.27.2023.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
      January 01, 2023 - ) from a referring hospital due to a left leg injury … a dosing error if a larger syringe were used.27,29,30 38 Approaches to Improving Patient Safety … related to system and product design such as how medications are manufactured and packaged) and active … lack of knowledge about what to report.43,44 • Better systems to report medication errors in a user-friendly … Do Not Use List Fact Sheet [Internet]. The Joint Commission. Accessed Feb 15, 2023.

2297. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72618/psn-pdf
      December 23, 2020 - Date First Implemented 2014-09-09 Problem Addressed Regardless of how successful an intervention is … and how to effectively guide an individual to choose a behavior or action is an ongoing question for … Social networks and norms influence how individuals eat and exercise. … Those types of projects are very easy to maintain as they do not require active sustainment efforts. … Dubner SJ, How to Save $32 Million in One Hour (Ep. 397). Freakonomics.

2298. Approach to Improving Patient Safety: Communication | PSNet
      psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication
      August 31, 2020 - do if a condition gets worse or doesn’t improve. … Effective communication can have a profound impact on how patients and caregivers perceive their care … providers, but also to use that communication as a means to include patients in the identification and … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not … find a cancer: how are non-specific symptom pathways for cancer investigation organised, and what are

2299. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846935/psn-pdf
      March 29, 2023 - / https://www.umassmed.edu/lifeline4moms/what-we-do/ https://saferbirth.org/patient-safety-bundles/ https … On the healthcare work side, clinicians and office staff should receive education on how to screen patients … services, or a reluctance to seek help. … be a priority, but opportunities exist to broaden research related to mental healthcare. … It is essential to understand how perinatal mood disorders can affect the parental dyad and the infant

2300. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33808/psn-pdf
      May 01, 2016 - have focused on how the care team can reduce the number of alarms and alerts. … On rounds, it is good practice to discuss how alarms should be used and to inquire about the patient's … experience with alarms, including how they may be interfering with sleep or rest. … Intensive care unit alarms—how many do we need? Crit Care Med. 2010;38:451-456. [go to PubMed] 5. … [go to PubMed] 15. Cvach MM, Currie A, Sapirstein A, Doyle PA, Pronovost P.