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

2301. In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring | PSNet
      psnet.ahrq.gov/perspective/conversation-susan-mcgrath-phd-and-george-blike-md-about-surveillance-monitoring
      April 26, 2023 - Thus, finding someone unresponsive when you come in to do vital signs or give a medication happens more … Your brain is designed to do that, to filter out noise. … As far as early warning and risk scores, we do think these can be used to identify people who need to … To do that, you need to design the system to detect a deviation that’s more severe and more sustained … We know that is a vulnerability: new people not understanding the system, its rationale, and how to use

2302. Root Cause Analysis | PSNet
      psnet.ahrq.gov/primer/root-cause-analysis
      March 30, 2022 - Background Root cause analysis (RCA) is a structured method used to analyze serious adverse events. … goals of identifying how the event occurred (through identification of active errors) and why the event … Task-related A patient requires emergency surgery which delays his dialysis treatment due to a  misplaced … This led the hospital to implement a series of systematic changes to reduce the likelihood of a similar … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not

2303. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33759/psn-pdf
      October 01, 2012 - of patient safety, but also how this knowledge can enhance clinical and organizational practices and … It is one of the many examples that demonstrate how AHRQ's grant-funded research often informs subsequent … Technology program launched an Ambulatory Safety and Quality (ASQ) grant initiative, which examined how … do in a fast-paced and busy ambulatory environment. … psnet.ahrq.gov//#ref17 https://psnet.ahrq.gov//#ref18 https://psnet.ahrq.gov//#ref19 for localized projects do

2304. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/860015/psn-pdf
      September 01, 2024 - Retention of a surgical item refers to possessing, keeping, or holding onto it; this word implies that … 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

2305. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49588/psn-pdf
      August 01, 2009 - Not only do patients have differing needs, but nurses have different experiences, competencies, and … It is important to mitigate the stressors of short staffing on a shift to shift basis. … transfer the patient back to his hospital bed when he was ready to do so. … How should nurses and the systems in which they operate respond? … Staff nurses who endure such shortages shift after shift do feel that care is unsafe.(9) A second option

2306. In Conversation with... Christie Allen about Maternal Safety and Perinatal Mental Health | PSNet
      psnet.ahrq.gov/perspective/conversation-christie-allen-about-maternal-safety-and-perinatal-mental-health
      March 29, 2023 - How do you think that’s impacted perinatal safety? … For example, we do not have a lot of inpatient facilities that allow for co-admission of a parent who … We need to normalize the experience of how hard it is to parent even when everything is going well, and … how hard it is to when you are also struggling with your own mental health. … We all have to do it and focus on perinatal mental health.

2307. COVID-19: Team and Human Factors to Improve Safety | PSNet
      psnet.ahrq.gov/primer/covid-19-team-and-human-factors-improve-safety
      September 15, 2024 - The TeamSTEPPS c urriculum can be used to train teams on how to conduct huddles and debriefings and … ideally focus on: Establishing a culture of safety: Encouraging every individual on a care team to … Therefore, healthcare organizations should do everything possible to provide as safe a working environment … Federal guidance on how to optimize supplies of PPE has been issued; to promote psychological safety … to achieve safety in a time of crisis.

2308. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853774/psn-pdf
      September 27, 2023 - Many patients who come to the ED do not need extensive workups and use few resources. … For example, a patient presents to triage and, if stable, goes to the waiting room until a treatment … How to make sense of a long list. Open Access Emerg Med. 2022 Jan 4;14:5-14. [Free full text] 13. … Acute mesenteric ischemia (part I) - Incidence, etiologies, and how to improve early diagnosis. … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not

2309. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49568/psn-pdf
      September 01, 2008 - Breastfeeding continued to be difficult, and the parents scheduled a face-to-face visit with the lactation … have 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

2310. In Conversation With... Freya Spielberg, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
      September 28, 2022 - One of the big challenges is, how do you pay for the community health workers? … A community health worker can work with the individual to show them how to get into patient portal, how … should have a home blood pressure [monitor] and know how to use it. … The community health workers can teach them how to do that, collect the information on their vitals if … models, logistically how you make this happen, and how to do it virtually, is going to be key for some

2311. Maternal Safety and Perinatal Mental Health | PSNet
      psnet.ahrq.gov/perspective/maternal-safety-and-perinatal-mental-health
      March 28, 2023 - How do you think that’s impacted perinatal safety? … For example, we do not have a lot of inpatient facilities that allow for co-admission of a parent who … We need to normalize the experience of how hard it is to parent even when everything is going well, and … how hard it is to when you are also struggling with your own mental health. … We all have to do it and focus on perinatal mental health.

2312. An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up | PSNet
      psnet.ahrq.gov/perspective/american-view-uks-patient-safety-enterprise-top-down-vs-bottom
      December 01, 2005 - series to get a sense of this.) … And how did the checklist notion play out in the UK? … To Err is Human: Building a Safer Health System. … Gawande A. The Checklist Manifesto: How to Get Things Right. … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not

2313. Clinical reasoning education at US medical schools: results from a national survey of internal medicine clerkship directors. | PSNet
      psnet.ahrq.gov/issue/clinical-reasoning-education-us-medical-schools-results-national-survey-internal-medicine
      October 12, 2022 - EndNote 7 XML Endnote tagged PubMedId RIS Download Citation Save Save to … PubMed citation Available at Related news article Save Save to your library … May 10, 2016 Does increased schedule flexibility lead to change? … September 23, 2020 Barriers to accessing nighttime supervisors: a national survey of … February 24, 2021 How to reduce stigma and bias in clinical communication: a narrative

2314. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/863649/psn-pdf
      February 28, 2024 - may treat patients as who you do things to rather than who you do things with. … and tools, and includes a diagram to show how everything fits together. … We do not want TeamSTEPPS to be implemented only after a patient has been harmed. … The way to do that is not to start off with a tragic story of a patient who was harmed. … huge impact on how they do their job in the future and how TeamSTEPPS can impact patient safety.

2315. Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures. | PSNet
      psnet.ahrq.gov/web-mm/missing-large-vessel-occlusion-stroke-patient-history-seizures
      August 31, 2022 - Learning Objectives Describe how health care providers should evaluate acute neurological deficits of … ENLS training addresses what emergency care providers should do in the first hour to best help patients … In this case, a stroke alert was not activated when the patient arrived in the ED, leading to a delayed … Emergency Neurological Life Support (ENLS): What to do in the first hour of a neurological emergency. … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not

2316. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49796/psn-pdf
      June 01, 2017 - The committee noted that this variation led to confusion among bedside nurses about how to https://psnet.ahrq.gov … Courtney Broaddus, MD In this commentary, we will review how chest tubes (thoracostomy tubes) function … There are few guidelines and even fewer trials available on when and how to remove a chest tube safely … Gawande A. The Checklist Manifesto: How to Get Things Right. … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not

2317. Statewide Telehealth Program Enhances Access to Care, Improves Outcomes for High-Risk Pregnancies in Rural Area | PSNet
      psnet.ahrq.gov/innovation/statewide-telehealth-program-enhances-access-care-improves-outcomes-high-risk
      November 13, 2024 - special considerations for the rural practice environment (e.g., cases in which Arkansas physicians do … do.   … to sign a contract with Medicaid. … Those interested are invited to contact the High-Risk Pregnancy Program for details on how they can … should explain how technology creates advantages for the partnering entity.

2318. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2021-09/spotlight_lost_in_transitions_of_care_09.22.2021_final.pdf
      January 01, 2021 - case describing how multiple ED encounters and long hospitalizations for a patient with sickle cell … they “avoid increasing opioid doses to ≥90” OME or “carefully justify a decision (to do so) based on … , may lead a pharmacist to refuse to fill a prescription if no provider calls back … In this example, a provider wants to switch a patient from Opioid A to Opioid B: 41 XX mg TDD Opioid … Utilizing OME: Equianalgesic Calculations (5) Using the equianalgesic table (slide 39), here is how a

2319. A Statewide Collaborative to Support Vaginal Birth and Reduce Unnecessary Cesarean Deliveries | PSNet
      psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-cesarean-deliveries
      July 23, 2024 - to report progress on measures back to hospitals on a regular basis Reports in a format that allows … 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 . … How much does it cost to give birth in the United States? It depends on the state. 

2320. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33842/psn-pdf
      January 01, 2018 - Leadership needs to provide the human resources required to do this work. … Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain … [go to PubMed] 20. Wright A, Aaron S, Sittig DF. … [go to PubMed] 28. Wachter R. How technology led a hospital to give a patient 38 times his dosage. … www.ncbi.nlm.nih.gov/pubmed/24951796 https://psnet.ahrq.gov//#ref28back https://www.wired.com/2015/03/how-technology-led-a-hospital-to-give-a-patient