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Showing results for "the change teams".

1841. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865610/psn-pdf
      April 24, 2024 - the Lean principles.3 The Lean teams evaluated their workflows to find gaps that could be targeted with … with negative patient care outcomes.3 In addition, the Lean teams oversaw the implementation of the … innovating site is committed to change, there is support from senior leadership, a multidisciplinary … Leaders to train multidisciplinary teams on the Lean CQI strategy. … Staff to participate in the Lean teams and create collaborative safety plans with patients.

1842. Patient Engagement and Safety | PSNet
      psnet.ahrq.gov/primer/patient-engagement-and-safety
      August 30, 2023 - While many patient safety interventions have used traditional models of effecting change, such as changing … to summon rapid response teams , rather than waiting for clinicians to respond. … The Agency for Healthcare Research and Quality and the World Health Organization sponsor a variety of … In addition to its prioritization of patient engagement through the National Patient Safety Goal, The … November 23, 2016 Experience with family activation of rapid response teams.

1843. Life-Threatening Infant Overdose of Sodium Chloride | PSNet
      psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride
      December 23, 2020 - After this fluid had been infusing for 16 hours, the PICU physician noted the error in the intravenous … The attending PICU physician who placed the incorrect fluid order met with the patient’s family, expressed … regret for the error, discussed the immediate effects and the next steps in the care of their baby, … For this patient, both the pharmacy technician and the pharmacist must have verified the additives as … Systems Change Needed/Quality Improvement Approach   Streamlined TPN re-ordering process   The

1844. Nothing Called Small Surgery | PSNet
      psnet.ahrq.gov/web-mm/nothing-called-small-surgery
      February 01, 2023 - One such process is the surgical count, the manual process of counting the materials used in the surgical … After the count is performed, the result is announced so the entire team involved in the procedure is … Third, a sign out procedure is performed at the conclusion of the case by the surgeon and the operating … room team; the process reviews the procedure performed and the implants retained with the patient, and … After Carpal Tunnel Surgery August 28, 2024 How does robotic-assisted surgery change

1845. Palliative Care: Comfort vs. Harm | PSNet
      psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
      December 04, 2016 - On the night shift, the bedside nurse went to see the patient at 3:00 AM to administer the next scheduled … The very decision to change the goal of care from sustaining life to a comfort-only approach is one such … In the present case, the decision to change the goal of care was made appropriately, based on both the … Health professionals should inform the patient and, with the agreement of the patient, the family about … the hydromorphone had shortened the life of the patient.

1846. X-ray Flip | PSNet
      psnet.ahrq.gov/web-mm/x-ray-flip
      August 10, 2019 - There was a moderate pneumothorax seen on the film on the anatomic left side (the side of the aortic … of the pneumothorax largely on the reading of the chest radiograph. … organizational processes and other contributing factors, it becomes more apparent where systematic change … To create a grass roots cultural change, we must translate the general tenets of a "high reliability" … High reliability organizational change for hospitals: translating tenets for medical professionals.

1847. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841493/psn-pdf
      December 14, 2022 - The relaxation of originating site restrictions, the opportunity for parity in payment, and a broadening … onset of the COVID-19 pandemic, which reduced the time and opportunity for healthcare operations or … patient’s existing medical home where there is access to the patient’s medical records and the physician … impact of individual patient factors, social determinants of health, and the fidelity of the telehealth … Telemedicine catches on: changes in the utilization of telemedicine services during the COVID-19 pandemic

1848. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33708/psn-pdf
      March 01, 2011 - For example, a shift change where the sender is returning is going to be very different from a service … change where it's the first time that a hospitalist may be meeting the patient and there will be no … , service change, or service transfer. … service change note, or an admission or a discharge summary. … We're starting to see change where people are really focusing on handoffs, and the residents are receiving

1849. A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care. | PSNet
      psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-can-improve-care
      July 08, 2022 - plan, however, there are cases in which decision-making capacity may change due to fluctuating mentation … the lack of multidisciplinary teams involved in a patient’s care. … For example, teams that do not include a social worker or mental health professional may not have the … and its prognosis, and the healthcare teams will have a better understanding of the values and goals … September 4, 2019 Measuring the teamwork performance of teams in crisis situations: a

1850. Healthcare professionals' perception of safety culture and the Operating Room (OR) Black Box technology before clinical implementation: a cross-sectional survey. | PSNet
      psnet.ahrq.gov/issue/healthcare-professionals-perception-safety-culture-and-operating-room-or-black-box-technology
      March 02, 2022 - View more articles from the same authors. … Measuring psychological safety and local learning to enable high reliability organisational change … Improving the implementation and adherence of the surgical safety checklist: a quality improvement project … in the operating room. … October 6, 2016 Reliability of a revised NOTECHS scale for use in surgical teams.

1851. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72624/psn-pdf
      January 05, 2021 - internal capacity necessary to continue to drive change. … Hospital and system-level teams should review the data regularly to allow for modification and refinement … to each hospital’s culture of safety, organization, and readiness to change. … At the initiation of the HEN 2.0 contract, LifePoint established the NQP as the framework to not only … use of interdisciplinary care teams, bedside shift reports, prioritizing patient engagement) and providing

1852. In Conversation with…Barbara A. Blakeney, MS, RN | PSNet
      psnet.ahrq.gov/perspective/conversation-withbarbara-blakeney-ms-rn
      August 01, 2005 - rapid response teams? … Nurses who have actually participated in urgent response teams tell me that the outcomes for the patients … only 16% of hospital CEOs listed patient safety among their top three concerns in 2004—no significant change … response teams and the use of evidence-based strategies to prevent ventilator-associated pneumonia. … blueprint to guide culture change in the nurse practice environment.

1853. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851389/psn-pdf
      July 31, 2023 - Safety, Radiology Quality and Safety, and the Center for Evidence-Based Imaging (CEBI) teams, identified … The focus of working group meetings is subject to change, and it may be expanded or altered based on … input from data and information technology teams to identify target patient populations. … For instance, duties conducted by grant staff were transitioned to operational teams. … Identify drivers of change to ensure patient safety and to minimize patient harm.

1854. Spotlight Case (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.206_slideshow.ppt
      October 01, 2009 - The resident came to the floor, told the nurse she was “stupid” and confidently explained that the case … The attending then called the operating room to cancel the case. … Case: Difficult Encounters (5) The following day, the CMO reviewed the nurse's intervention with the … today than in past A few senior physicians have lost privileges Safety innovations (rapid response teams … , time outs, etc.) have helped Teamwork training has helped change culture But more change is needed

1855. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication | PSNet
      psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
      August 01, 2012 - , so the two teams opted to keep the gastrostomy tube for gastric venting and to place a nasojejunal … The patient’s spouse then called the surgery clinic to change the follow-up visit; he revealed that his … transhepatic PEG tube, which contributed to the change in the original management plan. … A third systems solution might be to minimize the number of teams that offer percutaneous enteral tube … risk of adverse events, care teams should implement tactics to minimize the risk of adverse events.

1856. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33786/psn-pdf
      May 01, 2015 - Trauma teams have benefited from review of previous cases by identifying defects in teamwork (7), just … like professional sport teams that routinely use video to review their past performance. … illustrating technical procedures, video is used for dissemination of best practices, such as bedside shift change … Structured, routine post-action reviews, either by individuals or by teams, are also becoming more prevalent … appd001 https://psnet.ahrq.gov//#ref15 https://psnet.ahrq.gov//#ref3 become available, individuals and teams

1857. Count and Be Counted: Preparing Future Pharmacists to Promote a Culture of Safety | PSNet
      psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacists-promote-culture-safety
      April 01, 2006 - Teach students that the improved communication and teamwork skills that will support cultural change … RW: A lot of discussion in the patient safety world is about how to change the culture of physicians … I have personally seen a change, just in working with the committees that I'm on. … The technology will change the role of the pharmacist, to a greater focus on drug information provision … I was in New Zealand to give a talk, and because of the time change I couldn't sleep.

1858. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.116_slideshow.ppt
      February 01, 2006 - Transitions in Care Shift change over Two or more workers exchange mission-specific information, responsibility … Practices of high reliability teams: observations in trauma resuscitation. … stage Clinicians content with diagnosis of urinary tract infection for explanation of mental status change … change was due to urinary tract infection. … for this patient Post-turnover Clinicians did not reconsider diagnosis of UTI with mental status change

1859. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49698/psn-pdf
      December 01, 2013 - reduced hospital admissions is the use of teams of nurse practitioners (NPs) (or physician assistants … [PAs]) and physicians in managing SNF patients.(13) Such teams often have more time dedicated to the … These fundamental staffing principles are necessary but not sufficient to change behavior and improve … Teams of physicians and nurse practitioners (or physician assistants) can be highly effective in managing … Early learnings have led to adoption of cross-continuum teams in other states and regions as well

1860. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33828/psn-pdf
      March 01, 2017 - RW: How does the digitization of a health care work environment change the kinds of issues that we've … Change the ability to improve care, improve safety, and improve quality? … The effect of that system change is to reimagine even what the work is. … , between teams and teams. … change.