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

2341. Ensuring Patient and Workforce Safety Culture in Healthcare | PSNet
      psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
      March 27, 2024 - events and near misses, and how teams and leaders respond to events. 2 A positive patient and workforce … prior to a procedure) to their peers or leaders. … Psychologically safe cultures focus more on learning and how system failures lead to safety events rather … These studies suggest it is important to train leaders on how to best receive a safety concern in addition … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not

2342. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866826/psn-pdf
      September 25, 2024 - It was not clear how the gas pipes were misconnected, but this error apparently followed maintenance … When connecting a patient to a cylinder via a non- rebreather mask, it is especially important to ensure … Have a low threshold to change to a different gas supply Whenever desaturation occurs very rapidly, … climate - how emission taxation can achieve the coupling of cost-effectiveness and climate protection … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not

2343. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/857059/psn-pdf
      November 29, 2023 - Authors, reviewers and others in a position to control the content of this activity are required to … On day 64, the acute care surgery team was consulted to convert the PEG tube to a percutaneous gastrojejunostomy … The patient was discharged to a rehabilitation facility on day 74 with orders that included a surgery … determine how to communicate clearly and directly with patients and their families and support networks … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not

2344. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837215/psn-pdf
      July 08, 2022 - Authors, reviewers and others in a position to control the content of this activity are required to … 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 … 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

2345. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60790/psn-pdf
      February 23, 2022 - consistent with COVID-19 – or recent exposure to infected individuals - do not travel to the dental … Additionally, wearing PPE can be uncomfortable and may be physically challenging to do certain procedures … Practice roadmaps, and advice about how to access monies set aside for small businesses as part of … When and how to wash your hands. Centers for Disease Control and Prevention. … Teledentistry: How Technology Can Facilitate Access to Care.

2346. Post-Acute Transitional Services: Safety in Home-Based Care Programs | PSNet
      psnet.ahrq.gov/primer/post-acute-transitional-services-safety-home-based-care-programs
      April 24, 2024 - shown to have a positive impact on medication safety. … So many options, where do we start? An overview of the care transitions literature. … Home-based primary care: how the modern day “house call” improves outcomes, reduces costs, and provides … https://www.healthaffairs.org/do/10.1377/hblog20191003.276602/full/ Accessed November 8, 2021. … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not

2347. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60242/psn-pdf
      March 01, 2021 - 2002-01-01 Problem Addressed Many older adults, especially low-income and other vulnerable seniors, do … to-do” lists. … How They Did It Tools and Resources GRACE Training and Resource Center: Director, Dawn Butler, MSW, … J Am Geriatr Soc. 2006;54(7):1136-41. [ PubMed] Counsell SR, Callahan CM, Clark DO, et al. … [PubMed] Counsell SR, Callahan CM, Clark DO, et al.

2348. Patient Safety Indicators | PSNet
      psnet.ahrq.gov/primer/patient-safety-indicators
      June 15, 2024 - outcome measures, patient safety indicators may not provide detailed and actionable information on how … These stakeholders are more interested in how health care affects health outcomes and less interested … CMS responded to this report and other findings and concerns by developing a set of indicators to measure … to a 2010 OIG report , many hospitalized patients continue to experience adverse events and temporary … October 5, 2022 Positive approaches to safety: learning from what we do well.

2349. Hyponatremia Secondary to Home Parenteral Nutrition Error | PSNet
      psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error
      May 27, 2020 - Hyponatremia Secondary to Home Parenteral Nutrition Error Citation Text: Haas K, Lee A. … Changes are typically made to the PN components every few weeks to months depending on a patient’s laboratory … Families are taught proper PN administration, central line care, troubleshooting, signs of illness, and how … Go to PubMed Chandra R, Kesavan A. … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not

2350. Inpatient Transitions of Care: Challenges and Safety Practices | PSNet
      psnet.ahrq.gov/primer/inpatient-transitions-care-challenges-and-safety-practices
      June 15, 2024 - Challenges and Threats to Patient Safety Consider a scenario where a patient – Mr. … Due to the absence of a family member or caregiver, the healthcare team is unaware that Mr. … H is transferred to a critical care unit and his home medications, such as gabapentin for neuropathy … Strategies on how staff can incorporate families in medication communications are included as part … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not

2351. In Conversation with... Beverley H. Johnson about The Role of Patient's Family In Reducing Harm | PSNet
      psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-role-patients-family-reducing-harm
      June 14, 2023 - we do. … Each one has meaning for how to provide safe healthcare to a very diverse population. … Again, that’s something we like to help organizations do; it is a skill set you can develop and use. … I’m confident we’re going to do better going forward. … Visitation restrictions: is it right and how do we support families in the NICU during COVID-19?

2352. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60363/psn-pdf
      March 01, 2021 - Education on how to communicate: The Transitions Coach uses role playing and other tools to educate … patients and family members on how to communicate care needs effectively during subsequent encounters … condition and educates patients and family members on how to respond to these red flags, should they … how to respond in these situations. … Please do not accept training offers from other entities.

2353. Delayed Diagnosis of Kidney Transplant Complications | PSNet
      psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
      January 29, 2020 - The vascular surgery team then performed a right to left fem-fem bypass. … With multiple subspecialists involved in a patient’s care, it may be prudent to designate a team leader … to oversee the entire course of care for a patient to avoid missing critical periods of monitoring. … When patients such as the individual in this case do need multiple interventions, it is essential to … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not

2354. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2022-05/final_cme_reviewed_-_spotlight_missing_a_large_vessel_occlusion_stroke_04.14.2022_-_copy.pdf
      January 01, 2022 - : • Describe how health care providers should evaluate acute neurological deficits of less than 24 … – ENLS training addresses what emergency care providers should do in the first hour to best help … Routine Use of CT Angiography and Perfusion Imaging (3) 25 • Reliance on the NIHSS as a trigger to … Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. … Emergency Neurological Life Support (ENLS): What to Do in the First Hour of a Neurological Emergency.

2355. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49491/psn-pdf
      September 01, 2005 - resuscitation (CPR) but had never trained with the other team members and didn’t recall being trained in how … She commented on how difficult it had been to squeeze the Ambu bag toward the end of the code, a fact … she never had a chance to practice or apply that knowledge in a clinical setting. … It is very hard for a simulation center with a few mannequins to “scale up” an ACLS or CPR training … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not

2356. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73899/psn-pdf
      September 29, 2021 - care Recognize limitations of prescription drug monitoring programs (PDMPs) Recognize differences in how … 90” OME or “carefully justify a decision (to do so) based on individualized assessment of benefits and … 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: Once the conversion … Using the equianalgesic doses shown in Table 5, here is how a provider would convert a patient’s medication

2357. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33580/psn-pdf
      April 01, 2022 - While physicians make diagnostic and treatment decisions, they may only spend 30 to 45 minutes a day … with even a critically ill hospitalized patient, which limits their ability to see changes in a patient … Association, only 14 states have passed nurse staffing legislation as of March 2021 and most states do … As discussed in another WebM&M commentary, nurses do not currently have a required standardized transition … are an entrenched part of patient care, the link between interruptions and errors is one example of how

2358. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866055/psn-pdf
      May 29, 2024 - If leadership and frontline staff do not support the innovation, then it will struggle to get off the … Champions provide feedback to organization leadership on how the initial rollout of the innovation is … Sustaining This Innovation To sustain this innovation, Ascension found it essential to measure how the … Both groups must assess how the innovation is progressing in terms of reliability measures, like near … Retained surgical items: how do we get to zero? Jt Comm J Qual Patient Saf . 2023;49(1):1-2.

2359. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865466/psn-pdf
      March 27, 2024 - Gandhi, MD, MPH, described how systems-level and data-driven patient safety can drive greater equity … Researchers have developed a data analysis tool to assess group dynamics for vulnerabilities to bias … awareness-racial-and-ethnic-bias-and-potential-solutions-address-bias-use-health-care algorithms, even in algorithms that do … A key initiative to improve equity in patient safety starts at data gathering, as a key commentary notes … These efforts model how organizations may address the systemic factors that continue to perpetuate inequities

2360. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50699/psn-pdf
      November 26, 2019 - .2 For example, prolonged bed rest can lead to muscle wasting and the increased likelihood of a fall … A horizontal approach strives to address risk factors in the context of lowering overall facility-wide … It focuses on how interventions can prevent multiple types of harm at once and may provide a more comprehensive … unnecessary risks and ensure a patient-centered approach to care decision-making. … What do we know about frailty in the acute care setting? A scoping review.