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Showing results for "the change teams".

1861. Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up | PSNet
      psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow
      September 27, 2023 - to retrieve a recently ingested foreign body from the esophagus, the stomach or the first part of the … For a case of endoscopic foreign body retrieval like this one, many operating teams prefer endotracheal … A detailed history of the timing of the ingestion and the nature of the foreign body is important, as … When a new nurse is assuming care at shift change or break time, it is prudent for the physician to confirm … Whenever a change is made in the plan, the communication process needs to start over again.

1862. Hospital Admission Due to High-Dose Methotrexate Drug Interaction | PSNet
      psnet.ahrq.gov/web-mm/hospital-admission-due-high-dose-methotrexate-drug-interaction
      October 01, 2003 - The wound was debrided, and the patient received antibiotic therapy. … On the 10th day of antibiotics, she went to the outpatient oncology center for high-dose methotrexate … in accordance with the MAP cycle. … She returned the following day to the oncology center for routine leucovorin "rescue" and IV hydration … Pharmacist involvement on inpatient and ambulatory oncology teams can reduce avoidable ADEs.

1863. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50929/psn-pdf
      February 26, 2020 - The patient was seen in the Orthopedics clinic one month after his transfer to the SNF. … A typical OPAT team includes the primary care provider, the team treating the patient during the hospital … disconnect the medication bag from the IV line. … The patient or caregiver also needs to maintain the IV access site by flushing the line with normal … If active weekly monitoring of the patient had continued after discharge by the OPAT team, then the

1864. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49562/psn-pdf
      May 01, 2008 - of the atmosphere in the OR. … If the time out occurs at the time of incision, the surgeon is already scrubbed in, leaving only the … The intent of the time out is for the team to collectively discuss the case, but, given the requirements … , such as just prior to placement of a spinal anesthetic, and this is a practice that truly expert teams … Expert teams will also tailor the content of their time out to the specific procedure—using a combination

1865. Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review. | PSNet
      psnet.ahrq.gov/issue/incidence-nature-and-causes-avoidable-significant-harm-primary-care-england-retrospective
      November 13, 2019 - View more articles from the same authors. … The authors of this study retrospectively reviewed case notes from 14,407 primary care patients in the … 7 XML Endnote tagged PubMedId RIS Download Citation Related Resources From the … in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study … care: a cross-sectional study using the Clinical Practice Research Datalink (CPRD).

1866. SBAR improves communication and safety climate and decreases incident reports due to communication errors in an anaesthetic clinic: a prospective intervention study. | PSNet
      psnet.ahrq.gov/issue/sbar-improves-communication-and-safety-climate-and-decreases-incident-reports-due
      June 01, 2016 - View more articles from the same authors. … solutions to increase patient safety in the hospital: a mixed methods study. … August 18, 2021 Communication in interdisciplinary teams: exploring closed-loop communication … June 14, 2023 The 'go-between' study: a simulation study comparing the 'Traffic Lights … February 11, 2009 Hospitals combat errors at the 'hand-off.'

1867. Disparate perspectives: exploring healthcare professionals' misaligned mental models of older adults' transitions of care between the emergency department and skilled nursing facility. | PSNet
      psnet.ahrq.gov/issue/disparate-perspectives-exploring-healthcare-professionals-misaligned-mental-models-older
      May 11, 2022 - exploring healthcare professionals' misaligned mental models of older adults' transitions of care between the … View more articles from the same authors. … Based on interviews and thematic analysis, the authors explored mental models between the emergency department … April 28, 2021 Organizational readiness to change as a leverage point for improving safety … emergency department to the inpatient setting: a systematic review.

1868. Incivility and patient safety: a longitudinal study of rudeness, protocol compliance, and adverse events. | PSNet
      psnet.ahrq.gov/issue/incivility-and-patient-safety-longitudinal-study-rudeness-protocol-compliance-and-adverse
      June 21, 2016 - View more articles from the same authors. … Same Author(s) The impact of rudeness on medical team performance: a randomized trial. … April 12, 2019 Lessons learned for reducing the negative impact of adverse events on … coronavirus disease 2019 (COVID-19) pandemic: results from a national survey in the United States. … incident and association with the level of patient harm: a cross-sectional study in the Netherlands.

1869. 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

1870. 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.

1871. 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

1872. 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.

1873. 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.

1874. 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

1875. 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.

1876. 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

1877. 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.

1878. 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

1879. 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

1880. 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.