Results

Total Results: 3,566 records

Showing results for "the change teams".

1961. Medical Devices in the "Wild" | PSNet
      psnet.ahrq.gov/web-mm/medical-devices-wild
      March 27, 2024 - The medical team was preparing the patient for discharge the following day. … When the nurse raised the bed, unbeknownst to her, the tubing for the SCDs caught on the bed wheel lock … the wheel and brake of the bed. … During the reenactment, the staff realized it was possible for the tubing to catch the brake and unlock … This reactive change may be limited to just one hospital and likely did not result in more systemic changes

1962. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/861760/psn-pdf
      January 31, 2024 - drug tray by a previously assigned anesthesia nurse, who then signed out to another nurse at shift change … , and the anesthesiologist’s failure to read the label and identify the medication immediately before … The handoff at a provider change is a safety prompt that encourages medication reconciliation and individual … At shift change and perhaps without a proper handoff, a different nurse took the tray with the prepared … sequelae, but the patient was distressed by the experience and the error was avoidable.

1963. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60856/psn-pdf
      August 26, 2020 - With the benefit of hindsight, it seems obvious the interests of the patient, the family and the healthcare … the family.  …  operation in the evening distracts attention from the care of other patients in the operating suite … Systems Change Needed/Quality Improvement Approach  https://psnet.ahrq.gov//#15 Several system improvements … The different teams of physicians should have followed through on their preoperative multidisciplinary

1964. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836892/psn-pdf
      April 07, 2022 - The patient-to-nurse ratio is 2:1.5 According to the EC3 team, one benefit of the initiative is that … assigns a score from 1, indicating the most urgent, through 5, indicating the least urgent).5 The … evidence base for existing patient care pathways Discussing how to change the ED-focused culture to … of critical care, the EC3 director of operations, the emergency medicine director of operations, the … Getting Started with This Innovation To get started with the innovation, the EC3 leaders suggest the

1965. In Conversation With… Susan Haas, MD, MSc | PSNet
      psnet.ahrq.gov/perspective/conversation-susan-haas-md-msc
      March 01, 2019 - emergency room or change the volume or type of patients. … The fact that a given practice—whether it's a change in workflow or a computerized reminder—worked in … Leaders must be provided data along with the skills of interpretation and change management that allow … This onboarding, as well as ongoing educational efforts focused on systems thinking, change management … While reports alone do not drive necessary change ( 13 ), the information serves as the substrate for

1966. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/849592/psn-pdf
      May 31, 2023 - the involvement of the patient in the assessment and prevention planning process. … Using the program toolkit, nurses work with the patient, the patient’s family, and the available support … Under the program, nurses complete the assessment with the input of the patient and the patient’s family … Stakeholders (i.e., patients, families, care provider teams) willing and able to work together Support … Implementing teams should recruit and train nurse champions and establish processes for auditing and

1967. 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.

1968. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49532/psn-pdf
      March 15, 2007 - (ERCP) the following morning. … The physician evaluating the patient in the morning realized that no basal insulin was ordered and instituted … actual glucose level and the magnitude of change during the observed time intervals. … details of the algorithm. … change.

1969. Refused Medication Error | PSNet
      psnet.ahrq.gov/web-mm/refused-medication-error
      November 01, 2005 - Throughout the care in the hospital, the patient's refusal to take lactulose had been entered into the … communication is a critical element of patient safety and should be an ongoing priority for all patient care teams … Patient care teams need to have a thorough and realistic understanding of how their particular EHR system … Patient care teams should be actively engaged in the design (or redesign) of EHR features that present … Infused, Not Ingested November 1, 2005 Leading successful rapid response teams

1970. In Conversation with… Edward Tenner, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-edward-tenner-phd
      June 01, 2011 - ability to get things done, everything depended on the attitudes and the values of the people at the … through in health care, and we're trying to figure out how to change it. … While the team adjusted the table, it swung loose and the patient fell to the floor but sustained no … The hospital developed a report of the event for the manufacturer. … Departments are separated and teams resist scrutiny.

1971. 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

1972. 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.

1973. 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.

1974. 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

1975. 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.

1976. 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

1977. 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.

1978. 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

1979. 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

1980. 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.