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Total Results: 3,566 records

Showing results for "the change teams".

2061. Making Do | PSNet
      psnet.ahrq.gov/web-mm/making-do
      September 05, 2018 - After the patient was in the operating room and prepared for the procedure, the team discovered that … The nurses should have recognized the high probability that the patient was not pregnant and checked … Moreover, the surgeon should have reviewed the OR schedule to ensure that the case was listed correctly … If the wrong insufflator were used, the patient could have received greater than ten times the normal … Department of Veterans Affairs Chief Resident in Quality and Patient Safety Program: a model to spread change

2062. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33737/psn-pdf
      September 01, 2012 - The federal government has long been involved with the nursing profession, the largest component of the … workforce, as well as help advance the scientific foundation of the profession through the work of … agencies such as the National Institute of Nursing Research, the Veterans Administration, and the Agency … expansion of insurance coverage, the aging of the baby boomer generation, and the burgeoning population … to improve the delivery system and improve the health of the nation.

2063. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33604/psn-pdf
      December 15, 2024 - Correct medication use occurs when the "five rights" are followed, meaning the right dose of the right … medication is administered to the right patient, at the right time, and by the right route. … However, this simple phrase obscures the fact that the five rights must be individualized, as they are … The complexity of the medication prescribing and delivery processes can make it difficult to prove the … Given the latter factor, further studies that consider the return-on-investment of pharmacist-led safety

2064. 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

2065. Discharged with IV antibiotics: When issues arise, who manages the complications? | PSNet
      psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
      October 10, 2017 - 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. … If active weekly monitoring of the patient had continued after discharge by the OPAT team, then the SNF … Ongoing monitoring of the clinical status of the infection is another responsibility of the OPAT team

2066. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33776/psn-pdf
      January 01, 2015 - is not working and you need to change it." … Many times, people talk about culture change without having the hard conversations about what exactly … Technology too often is dictating the workflow change and that's not ideal. … expensively with fewer change orders and less rework. … Starting to train managers and leaders and to change the culture, that probably takes 3 to 5 years where

2067. In Conversation With... Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-ann-gaffey-rn-msn-cphrm-and-bruce-spurlock-md
      March 30, 2020 - taskforce for the Coalition to Improve Diagnosis, am the Vice Chair for the National Coordinating Counsel … The final thing that I think is helpful is that we are identifying the setting that the patient safety … BS: Since the last report, one of the things that has matured the most on the technology front is the … capital resources, and also preparing for things like significant supply change disruption or human … as much on the plan for implementation as on the specifics of the PSP itself. [3] Finally, the presentation

2068. What Happened on Telemetry? | PSNet
      psnet.ahrq.gov/web-mm/what-happened-telemetry
      January 18, 2012 - The central monitor with the tracings is sometimes on the same unit as the patient and sometimes in another … The fact that no one answered the phone in this case also raises the issue of the adequacy of staffing … on the patient to the moment the bedside nurse is notified of the abnormal rhythm. … personnel," (ii) a telephone system with continuously updated nurse assignments that were reviewed each change … Will equipment change from what staff is currently familiar with?

2069. Hospitals combat errors at the 'hand-off.' | PSNet
      psnet.ahrq.gov/issue/hospitals-combat-errors-hand
      August 17, 2016 - Citation Text: Hospitals combat errors at the 'hand-off.' Landro L. … View more articles from the same authors. … January 13, 2016 The most crucial half-hour at a hospital: the shift change. … October 7, 2015 The key to reducing doctors' misdiagnoses. … and emergency department staff in the deteriorating patient.

2070. Healthcare Excellence Canada. | PSNet
      psnet.ahrq.gov/issue/canadian-patient-safety-institute
      August 24, 2022 - It was formed in March 2021 through the merging of the Canadian Foundation for Healthcare Improvement … and the Canadian Patient Safety Institute. … Measurement and Monitoring of Safety Through the Eyes of Patients and Their Care Partners. … July 20, 2005 Perspective Organizational Change in the … More About The Topic Health Care Providers Media Policy Makers Patients

2071. Safety Culture: Theory, Method and Improvement. | PSNet
      psnet.ahrq.gov/issue/safety-culture-theory-method-and-improvement
      August 02, 2016 - View more articles from the same authors. … This book describes the fundamentals of safety culture in the context of well-known incidents in high-risk … February 6, 2019 Safety Culture: Building and Sustaining a Cultural Change in Aviation … May 11, 2016 Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health … April 23, 2014 The Measurement and Monitoring of Safety.

2072. Hospitals overhaul ERs to reduce mistakes. | PSNet
      psnet.ahrq.gov/issue/hospitals-overhaul-ers-reduce-mistakes
      August 17, 2016 - View more articles from the same authors. … February 17, 2016 At the hospital, better responses to those beeping alarms. … January 13, 2016 The most crucial half-hour at a hospital: the shift change. … October 7, 2015 The key to reducing doctors' misdiagnoses. … Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department

2073. The MacArthur Fellows Program: Eric Coleman. | PSNet
      psnet.ahrq.gov/issue/macarthur-fellows-program-eric-coleman
      June 11, 2013 - Citation Text: The MacArthur Fellows Program: Eric Coleman. MacArthur Foundation. … Research to Inform Advocacy and Action and Expand the Evidence Base. … January 17, 2024 Just culture: the foundation of staff safety in the perioperative environment … September 7, 2022 The Uneven Burden of Maternal Mortality in the U.S. … Improving Diagnostic Safety and Quality April 26, 2023 Patient safety teams

2074. Thinking about our thinking as physicians. | PSNet
      psnet.ahrq.gov/issue/thinking-about-our-thinking-physicians
      August 24, 2016 - View more articles from the same authors. … Copy Citation Related Resources From the Same Author(s) How Doctors Think … August 24, 2016 What's the trouble? How doctors think. … June 21, 2006 Teamwork and communication in surgical teams: implications for patient … August 7, 2019 Learning from tragedy: the Julia Berg story.

2075. What surgeons leave behind costs some patients dearly. | PSNet
      psnet.ahrq.gov/issue/what-surgeons-leave-behind-costs-some-patients-dearly
      August 29, 2012 - View more articles from the same authors. … done to stop the deadly bacteria C. diff. … November 14, 2018 When is the surgeon too old to operate? … February 13, 2019 The computer will see you now. … the retention of foreign objects.

2076. Dealing with a medical mistake: should physicians apologize to patients? | PSNet
      psnet.ahrq.gov/issue/dealing-medical-mistake-should-physicians-apologize-patients
      February 17, 2016 - Copy Citation Related Resources From the Same Author(s) Voluntary medical … February 17, 2016 The July effect: an analysis of never events in the nationwide inpatient … Patient safety and the dermatologist. … March 29, 2017 The Medical Apology: Making It Right When Things Go Wrong. … April 25, 2016 Why empathy may be the best risk management strategy.

2077. Quality and Safety Education for Nurses. | PSNet
      psnet.ahrq.gov/issue/quality-and-safety-education-nurses-0
      June 01, 2016 - Copy Citation Related Resources From the Same Author(s) Josie's Story: A … June 1, 2016 Clearing the Error: Using Public Deliberation to Define Patient Roles as … Partners in the Diagnostic Process. … June 8, 2023 The critical need for nursing education to address the diagnostic process … March 22, 2006 View More See More About The Topic Nurse Managers Educators

2078. Errors test openness at Beth Israel Deaconess. Disclosures will benefit hospital, president insists. | PSNet
      psnet.ahrq.gov/issue/errors-test-openness-beth-israel-deaconess-disclosures-will-benefit-hospital-president
      August 13, 2008 - View more articles from the same authors. … September 9, 2020 The July effect: an analysis of never events in the nationwide inpatient … March 13, 2019 The other opioid crisis: hospital shortages lead to patient pain, medical … November 14, 2018 When is the surgeon too old to operate? … February 13, 2019 The computer will see you now.

2079. 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

2080. 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.