Results

Total Results: 3,566 records

Showing results for "the change teams".

1981. 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

1982. Meaningful Measurement in Patient and Family Engagement | PSNet
      psnet.ahrq.gov/perspective/meaningful-measurement-patient-and-family-engagement
      March 10, 2021 - Initiative PFE Measures PfP PFE Measures: Planning Checklist for Scheduled Admissions Shift Change … Since then we have expanded into Quality Improvement Organizations (QIOs) , research teams, measure … on the color of the paint on the wall. … evolution over time, and as I look back on it and think about where we are now, recent pivotal points of change … You can't improve care at the bedside without changing the system, and you can't change the system if

1983. 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.

1984. Fixing Healthcare Delivery. | PSNet
      psnet.ahrq.gov/issue/fixing-healthcare-delivery
      February 05, 2014 - This online course presents  teamwork , systems design, leadership, and change management as strategies … The course includes instructional videos, interactive questions, essays, and discussions. … Copy Citation Related Resources From the Same Author(s) The PROMISES Project … July 12, 2017 Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era. … April 16, 2018 Safety Is Personal: Partnering With Patients and Families for the Safest

1985. The bell curve. | PSNet
      psnet.ahrq.gov/issue/bell-curve
      September 28, 2017 - Newspaper/Magazine Article The bell curve. … View more articles from the same authors. … A sensitive portrayal of the challenges in defining quality and implementing change even when practitioners … January 14, 2011 The checklist. … April 1, 2015 The best medical care in the U.S.

1986. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43959/psn-pdf
      September 01, 2016 - Evaluation of an automated surveillance system using trigger alerts to prevent adverse drug events in the … Evaluation of an automated surveillance system using trigger alerts to prevent adverse drug events in the … The authors found that more than 40% of the alerts required pharmacist intervention, and that over 90% … of pharmacist recommendations were accepted by the prescribing physicians. … The proliferation of false-positive warnings is a primary contributor to alert fatigue, and although

1987. ASHP statement on the role of the medication safety leader. | PSNet
      psnet.ahrq.gov/issue/ashp-statement-role-medication-safety-leader
      June 16, 2019 - Organizational Policy/Guidelines ASHP statement on the role of the medication safety … Citation Text: ASHP Statement on the Role of the Medication Safety Leader. … outlines the responsibilities of such a role.  … Areas of focus include leadership, medication safety expertise, change management, research and education … Role of the Medication Safety Leader.

1988. Preventable Transfer to the Hospital | PSNet
      psnet.ahrq.gov/web-mm/preventable-transfer-hospital
      March 31, 2022 - The plan was to transition the patient to hospice the following day. … and care settings from the hospital to the SNF. … documents, together with other barriers to effective communication, such as frequent rotation of care teams … , long wait times during the transfer process, and lack of knowledge of the resources available at the … Advanced care planning should be implemented and documented in a timely manner, updated as conditions change

1989. Triple Handoff | PSNet
      psnet.ahrq.gov/web-mm/triple-handoff
      March 01, 2004 - List Kotter’s 8 steps to leading change. … by a conceptual framework to manage the change, using Kotter's 8-step approach.( 23 ) 1. … Consolidate improvements, creating more change. … A change framework can be an effective strategy to implementing safe and effective signout systems. … Leading change: why transformation efforts fail. Harv Bus Rev. March 1995. Figures Figure 1.

1990. Advance Alert Monitor Program: An Automated Early Warning System for Adults At Risk for In-Hospital Clinical Deterioration | PSNet
      psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults-risk-hospital
      October 30, 2024 - patient’s condition and/or align the care plan with the goals of the patient. … Clinical and technology teams worked collaboratively to develop and finalize the evidence-based criteria … Work with the information technology team to integrate the program into the organization’s EHR. … Identify the team members who will be trained to monitor and review the AAM scores and facilitate the … The clinical team then works collaboratively with the patient and the family to identify or clarify the

1991. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/850678/psn-pdf
      June 14, 2023 - patient’s condition and/or align the care plan with the goals of the patient. … Clinical and technology teams worked collaboratively to develop and finalize the evidence- based criteria … Description of the Innovative Activity The AAM program uses predictive analytics to scan the patient … If the score and review of the chart confirm signs of potential clinical deterioration, the virtual … The clinical team then works collaboratively with the patient and the family to identify or clarify the

1992. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867428/psn-pdf
      December 18, 2024 - One of the implementation issues is that any change in practice in an acute care environment requires … In this environment, change first requires support from leadership. … Leadership by nurse managers is needed to support practice change at the bedside and to provide proper … If nothing changes, they reinforce it and change the date. … We are trying to change that message; just like you should eat well every day, you should exercise every

1993. 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

1994. Situational (Un)Awareness | PSNet
      psnet.ahrq.gov/web-mm/situational-unawareness
      August 01, 2009 - Subsequent analysis of the delay found the following: When an order is entered in the computerized provider … but the computer converted that to 9:00 PM on Wednesday, a change he did not notice. … the medication to the unit. … Had the physician communicated the plan of care with the patient's nurse, or the pharmacist instructed … Evaluating the medication process in the context of CPOE use: the significance of working around the

1995. Medication/Drug Errors | PSNet
      psnet.ahrq.gov/curated-library/medicationdrug-errors
      March 12, 2021 - The study also identified 160 attempts to exceed the programmed dosing limit; while these represented … a small number of violations over the entirety of the study period, the attempts involved high-risk … The investigation determined various individual and system failures that contributed to the incident, … The National Patient Safety Goals (NPSGs) are one of the major methods by which The Joint Commission … In light of the current opioid crisis, the use of opioids to manage noncancer-related chronic pain in

1996. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49448/psn-pdf
      June 01, 2004 - The resident called the family to obtain informed consent for the procedure. … The next morning, the surgeon returned to the bedside, where the family again refused to provide consent … Long-standing policies and procedures have become ossified, and surgeons resist change, particularly … In any case, because of the vulnerability of the old system, the days of the stat page to the intern … If the permit can't be found, the attending must redo the permit in the PACU.

1997. 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.

1998. 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

1999. 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

2000. 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.