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Showing results for "the change teams".

1921. How incident reporting systems can stimulate social and participative learning: a mixed-methods study. | PSNet
      psnet.ahrq.gov/issue/how-incident-reporting-systems-can-stimulate-social-and-participative-learning-mixed-methods
      November 04, 2020 - View more articles from the same authors. … Same Author(s) The doctor was rude, the toilets are dirty. … Utilizing 'soft signals' in the regulation of patient safety. … the patients' perspective: a focus group study. … December 9, 2020 Exploring psychological safety in healthcare teams to inform the development

1922. Patient and Family Roles in Safety | PSNet
      psnet.ahrq.gov/perspective/patient-and-family-roles-safety
      June 14, 2023 - But we can change and improve. … An opportunity arose in the spring of 1992 to make this change. … We worked together with them on the Better Together international campaign to change the concept of families … Hospitals are beginning to change the concept of families as “visitors,” returning to the belief that … In Canada, across the entire province of Alberta they had two Rapid Response Teams of patient and family

1923. A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion | PSNet
      psnet.ahrq.gov/web-mm/complicated-course-severe-alcohol-withdrawal-dexmedetomidine-infusion
      June 14, 2023 - following: initial starting rate, incremental units by which the rate can be adjusted without a change … It is possible that there was a staffing change and the nurse who received the free text order did not … change and the change in medication dosage. … The nurses should have alerted the physician staff about the change and more importantly, when the patient … physician to the dose change and why medication weaning was impossible.

1924. 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

1925. Discharge Instructions in the PACU: Who Remembers? | PSNet
      psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers
      August 05, 2009 - After the surgery, the surgeon briefed the patient in the post-anesthesia care unit (PACU) on his findings … change from what had been originally anticipated. … explained specifically how the rehabilitation guidelines had changed based on the new findings and change … No one communicated the change to her husband (the designated caregiver), and the written discharge instructions … Residents' responses to medical error: coping, learning, and change.

1926. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. | PSNet
      psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
      March 15, 2023 - The patient recovered without change in respiratory symptoms or vital signs in the PACU. … The fellow assumed that the attending physician had reviewed the CXR and submitted the discharge orders … thought the other had reviewed the CXR. … The bedside nurse presumed the CXR was read as normal after hearing from the patient that the attending … The quick turnover and potentially rapid expansion of pneumothorax requires post-bronchoscopy care teams

1927. Nursing and Patient Safety | PSNet
      psnet.ahrq.gov/primer/nursing-and-patient-safety
      September 15, 2024 - of the patient’s condition to the team. … The nurse-to-patient ratio is only one aspect of the relationship between the nursing workload and patient … landmark Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health . … The multiple factors discussed including the high-risk nature of the work, increased stress caused by … March 23, 2011 The Future of Nursing: Leading Change, Advancing Health.

1928. The Johns Hopkins Venous Thromboembolism (VTE) Collaborative Studies and Implements Methods to Prevent Avoidable Cases of Hospital Associated VTE | PSNet
      psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-implements-methods
      June 19, 2024 - risk and creating treatment plans Incentives for improved provider performance A bottom-up approach to change … that a patient had refused the medication, the educator met with the patient. 23 Context of the Innovation … At the time of the start of the initiative, the VTE Collaborative found that only 33% of patients were … dose of VTE due to patient refusal (5.9% to 3.4%) while the patient refusal rate did not change in the … risk and creating treatment plans Incentives for improved provider performance A bottom-up approach to change

1929. Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase. | PSNet
      psnet.ahrq.gov/issue/multiple-component-patient-safety-intervention-english-hospitals-controlled-evaluation-second
      February 23, 2011 - This study is the second phase of the United Kingdom's Safer Patients Initiative (SPI), a large-scale … An accompanying editorial [see link below] discusses the study findings and emphasizes the continued … December 30, 2014 The effect of the electronic transmission of prescriptions on dispensing … , 2023 Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change … Health Care from the Inside Out.

1930. 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.

1931. 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

1932. 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.

1933. 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.

1934. 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

1935. 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.

1936. 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

1937. 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.

1938. 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

1939. 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

1940. 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.