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Showing results for "the change teams".

2141. Why accountability sharing in health care organizational cultures means patients are probably safer. | PSNet
      psnet.ahrq.gov/issue/why-accountability-sharing-health-care-organizational-cultures-means-patients-are-probably
      May 27, 2020 - The recognition that humans err and the situation of response to error in a constructive and nonpunitive … Copy Citation Related Resources From the Same Author(s) What constitutes … August 31, 2022 Error disclosure in pathology and laboratory medicine: a review of the … August 2, 2023 Disclosing medical errors: prioritising the needs of patients and families … October 3, 2017 View More See More About The Topic Hospitals Ambulatory

2142. Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial. | PSNet
      psnet.ahrq.gov/innovation/pharmacist-led-mobile-health-intervention-and-transplant-medication-safety-randomized
      April 07, 2021 - View more articles from the same authors. … care or the TRANSAFE Rx intervention. … During the 12-month study period, findings show that the TRANSAFE Rx intervention significantly reduced … elderly (The IMMENSE study) - a randomized controlled trial. … November 30, 2022 Psychological safety in intensive care unit rounding teams.

2143. Critical Echocardiogram Result Lost to Follow-up | PSNet
      psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
      July 31, 2023 - The admitting physician reviewed the echocardiogram done on the prior hospitalization and noted there … On review, the echocardiogram results had populated into the electronic health record after the patient … The results were sent to the inbox of the ordering resident, who was not on the primary service taking … The primary service taking care of the patient at the time also did not follow up the patient’s echocardiogram … up the echocardiogram results; the resident who had ordered the echocardiogram was not on the primary

2144. Haste Makes Care Unsafe | PSNet
      psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
      January 07, 2015 - In the ICU, the nurse who assumed care of the patient noticed that the PA catheter waveform was dampened … Fortunately, the nurse recognized the situation quickly, and the resident deflated the balloon and withdrew … the final segment of the case. … Automatic resistance to the implementation of checklists (it's a change, a possible slight increase in … in medical teams.

2145. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33691/psn-pdf
      December 01, 2009 - Once we defined the extent of the problem and the relationship between disruptive behaviors and both … Commitment needs to come both from the top administrative and clinical leadership teams including the … report events either in fear of retaliation or because they report and report and nothing ever seems to change … on the part of the senior management and clinical leadership to address the issue head on. … The scope of the outcome was varied.

2146. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49677/psn-pdf
      February 01, 2013 - of the subclavian line was actually within the lung. … different treatment teams. … for clinicians, perceived lack of time for use in emergent situations, and cultural resistance to change … The optimal position for the catheter tip placed in the subclavian or internal jugular vein is at the … , the ICU team, and the cardiologists.

2147. Double Trouble | PSNet
      psnet.ahrq.gov/web-mm/double-trouble
      August 01, 2012 - The case begins with the patient having been admitted to the hospital with hypoglycemia. … to the new setting of care. … Interventions involving multidisciplinary teams that are initiated in the hospital or ED setting and … context of any change in the treatment regimen. … Gurwitz, MD The Dr.

2148. Autopsy Revelation | PSNet
      psnet.ahrq.gov/web-mm/autopsy-revelation
      December 01, 2007 - The mother described the current episode as the sudden onset of severe pain, which initially seemed to … The Commentary The discharge diagnosis of renal colic in this case almost certainly reflected the operation … change in the rates at which autopsy reveals clinically important diagnoses that had escaped antemortem … The value of the autopsy in three medical eras. … June 22, 2022 Expanding the scope of Critical Care Rapid Response Teams: a feasible approach

2149. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49621/psn-pdf
      March 01, 2011 - The Case A 22-month-old infant was admitted to the hospital in the late afternoon with a viral infection … The night nurse communicated the minimal intake of fluids and poor urine output to the day nurse at the … 7:00 AM change of shift. … The fifth colleague puts 3,000 mg on the table. … scores or rapid response teams.

2150. In Conversation With... Jack Westfall, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-jack-westfall-md-mph
      September 28, 2022 - the test, (4) the laboratory reporting the test result back to the practice, (5) the result reported … back to the clinician, and (6) the result reported by the clinician back to the patient. … So, the change from a three-by-five card to broader evidence-based charting and to EHRs is a good example … I think there’s been a broad culture change over the last 20 years related to this, but I think there … provision of whole-person, integrated, accessible, and equitable healthcare by interprofessional teams

2151. Webmm Spotlight Suicide Risk Assessment (pdf file)
      psnet.ahrq.gov/sites/default/files/2019-11/webmm_spotlight_suicide_risk_assessment.pdf
      January 01, 2019 - parking lot of the ED expressing suicidal ideation (SI) and brought into the ED • Triage nurse entered … Commentary By Glen Xiong, MD & Debra Kahn, MD 9 Systems Approach to Change In both cases, patients … that carries over onto Progress Note – More likely to be seen by nursing staff and primary medical teams … PDSA (plan, do, study, act) cycle for quality improvement • The acronym succinctly captures the points … severity and acuity of the psychiatric disorders that underlie the suicide risks • Treatment for

2152. Adverse Drug Event (ADE) Surveillance and Pharmacist Counseling | PSNet
      psnet.ahrq.gov/innovation/adverse-drug-event-ade-surveillance-and-pharmacist-counseling
      June 28, 2023 - Patient responses to the IVR survey were simultaneously emailed to the pharmacist The pharmacist assessed … The pharmacist would document the adverse drug effect in the medical record and alert the prescriber … The Innovation team identified 26 clinics to participate in the study. … The pharmacist documented the interaction with the patient, and any probable or possible ADE was documented … Identify the commonly prescribed medications across the clinical conditions to incorporate into the automated

2153. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected | PSNet
      psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
      September 25, 2024 - The attending gastroenterologist and endoscopist were serially dilating the esophagus with larger and … One of the main goals is to understand the healthcare work processes that could be changed to eliminate … etiology of the stricture and the experience of the proceduralist often determine which technique is … performance of the procedure. 1 , 6 No specific sedation protocol has been established as the best, … a unified plan before the procedure begins may increase the risk for unexpected adverse events.

2154. Computerized Provider Order Entry | PSNet
      psnet.ahrq.gov/primer/computerized-provider-order-entry
      March 15, 2025 - Spurred by the 2009 federal HITECH Act and the accompanying Meaningful Use program, now known as the … quantity of the medication in the correct form. … Administration : the medication must be received by the correct person and supplied to the correct patient … at the right time in the right dosage. … effectiveness of interruptive prescribing alerts in ambulatory CPOE to change prescriber behaviour and

2155. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49431/psn-pdf
      January 01, 2004 - (Table 1).(3) The second step in the Bayesian approach is to adjust the initial probabilities using … The ED team correctly decided that the patient would benefit from observation in the CCU. … Case & Commentary: Part 2 The team re-reviewed the chest x-ray and discovered an abnormality in the … As in this case, the x-ray may show the 'calcium sign'—a separation by greater than 1 cm between the … The patient was transported to the operating room.

2156. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50613/psn-pdf
      October 30, 2019 - quo–based than economic or policy-based or malpractice system or any of that, how do you begin to change … The fork-in-the-road choice is between the right thing to do and the easy thing to do. … change culture, what does that look like to get to a better place? … The theory of change is that by integrating the mom's voice into the decision making as a member of … from the minute the cervix is fully dilated to the head passing the narrowest part of the pelvis and

2157. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33760/psn-pdf
      February 01, 2014 - error, which means you forget to do the last element in the sequence—the cleanup bit. … This is the notion of the sterile cockpit, the "no interruption zone." … As we know one of the most important rules for activating medical emergency teams is concern by clinicians … to conform to the needs of the record. … , the people around you, and the task at hand.

2158. Rethinking Root Cause Analysis | PSNet
      psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
      August 21, 2016 - Investigations of questionable quality Teams may not have in-depth training in accident investigation … These factors may significantly limit the scope of the investigation, the recommendations, and the report … Train a designated team RCA2 teams should be composed of four to six people. … Teams should not include individuals who were involved in the event or close call being reviewed, but … Diagramming, Five Rules of Causation, Action Hierarchy, Process/Outcome Measures) should be used by teams

2159. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49739/psn-pdf
      August 21, 2015 - The patient reported feeling more comfortable after the tracheostomy than he felt with the endotracheal … The first change is typically performed by the proceduralist. … During the expiratory phase, airflow is redirected to the upper airway, passing through the larynx, … During the first 5–7 days after tracheostomy, before the stoma is well formed, dislodgement of the tube … secure the airway.

2160. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867656/psn-pdf
      February 26, 2025 - Earlier in healthcare delivery, people talked about change management and referenced the work of Peter … the original impetus for the learning. … They never really talked to the implementation teams that were doing the improvement work. … If there is a change in a CEO, for example, the priorities will shift and change. … with the priorities of the system.