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Showing results for "the change teams".

2221. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49810/psn-pdf
      November 01, 2017 - On the night shift, the bedside nurse went to see the patient at 3:00 AM to administer the next scheduled … The very decision to change the goal of care from sustaining life to a comfort-only approach is one … In the present case, the decision to change the goal of care was made appropriately, based on both the … the hydromorphone had shortened the life of the patient. … The fact that the care team chose to review the case means that they've already taken the first step

2222. Communication During Transitions of Care | PSNet
      psnet.ahrq.gov/perspective/communication-during-transitions-care
      July 10, 2024 - and the patient’s readmission to the hospital. … shown to strengthen resilience, improve teamwork, and reduce risk of adverse events among healthcare teams … care teams. … I-PASS and TeamSTEPPS, can foster a culture of safety and improve communication skills among healthcare teams … The Joint Commission. Sentinel Event Data 2022 Annual Review . The Joint Commission; 2023.

2223. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49581/psn-pdf
      March 21, 2009 - The Commentary Over the past decade, the patient safety movement has actively worked to shift the focus … A more thorough review of the error reveals that the new policy was actually at the root cause of the … The immediate success or failure of a strategic change can be easily identified once the change has … involved as to the cause of the error. … shift change, breaks in care, and changes in level of care.

2224. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_stable_airway_slides_final.pptx
      January 01, 2024 - of change is based on the placement approach (percutaneous or surgical), the patient's ability to heal … tracheotomy tract is more prone to a false passage occurring during the first tube change, resulting … in loss of the airway.11 Therefore, the first tracheostomy change is typically performed by a physician … type of placement is unknown, no change should occur within the first five to seven days of the procedure … change. 

2225. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/857061/psn-pdf
      November 27, 2023 - Another big change is the feedback and assessment that must occur frequently across the entire curriculum … Develop a plan for monitoring quality improvement change. … Students also may participate in the change process of a quality improvement committee, or in implementing … entry-level students can also have these opportunities to engage in initiatives, policy discussions, change … They could also be part of looking at what change might be needed, including coming up with recommendations

2226. In Conversation with Eric Thomas about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement | PSNet
      psnet.ahrq.gov/perspective/conversation-eric-thomas-about-zero-harm-striving-reduce-preventable-harms-point
      September 24, 2024 - accountable for it, then at the unit level, the nurse manager, the medical director, the clinicians … And then he remarks, “Major change emerges from aggregation of marginal gains.” 1 So it is these small … He has been the coach of the University of Texas men's swim team since 1979, and his teams have won 15 … It wouldn't be hard to change that structural measure from zero harm to improvements on reducing preventable … Your symptoms are going to change in the meantime. We are going to communicate about it.

2227. Listen to the Family | PSNet
      psnet.ahrq.gov/web-mm/listen-family
      April 15, 2015 - The surgical resident attempted to convince the daughter that the patient's life was in danger, but the … 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.

2228. The Safety of Medical Devices | PSNet
      psnet.ahrq.gov/perspective/safety-medical-devices
      June 01, 2011 - 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. … 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.

2229. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866343/psn-pdf
      December 31, 2024 - The next morning, while she remained as a boarder in the ED awaiting transfer to the ward, the patient … By the time the effects of labetalol wore off, she had already been seen by the https://psnet.ahrq.gov … Between her admission evaluation in the ED and her re-evaluation by the day team on the medical ward … Was the overnight nursing supervisor or the charge nurse on the receiving unit empowered to raise questions … The role of the clinical examination in patients with heart failure.

2230. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49519/psn-pdf
      September 01, 2006 - 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.

2231. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33803/psn-pdf
      January 01, 2015 - disparities data in the report did not include the effects of the 2014 coverage expansion. … change-of-shift reports, assuring that during shift changes it is not simply one nurse talking with … What's the obstacle to getting the good news out? … had computers and could embed practices in them that it wouldn't be 7 years between an article and a change … It does make sense that change would take some time.

2232. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33713/psn-pdf
      June 01, 2011 - While the team adjusted the table, it swung loose and the patient fell to the floor but sustained no … The surgical department was aware of the table's flaws, but was willing to trade off the table's safety … The hospital developed a report of the event for the manufacturer. … lever on the side of the table's head end control housing. … Departments are separated and teams resist scrutiny.

2233. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836885/psn-pdf
      May 16, 2022 - Successful teams not only have medical expertise and mastery of resuscitation skills, but also demonstrate … until the patient was in the radiology suite. … and key ACLS metrics.9 Teams are comprised of members from diverse disciplines with delineated roles … Successful teams not only have medical expertise and mastery of resuscitation skills, including use … Resuscitation team roles and responsibilities: in-hospital cardiopulmonary arrest teams.

2234. Missed CANDOR Implementation Opportunities. | PSNet
      psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
      November 11, 2020 - The cardiac surgeon discussed the problem with the patient and his wife, including the numerous risks … after the event but later on after the impact of the event has settled in for the family. … Therefore, after fully discussing the case, the committee recommended that the surgeon reach out to the … If all the details of the care given to the patient are not yet known at this time, the liaison should … November 11, 2020 Culture change in infection control: applying psychological principles

2235. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60329/psn-pdf
      May 14, 2020 - focused on maritime and aviation telehealth, as well as supporting remote research stations and remote teams … At the originating site where the patient is, whether in DC or in the middle of the ocean, we need to … The hands-on person becomes the telepresenter as well as the treating clinician. … There is a workflow change there. How do you confirm their insurance? … That is critically important for any large cultural and technological change.   

2236. In Conversation With… Kaveh Shojania, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-kaveh-shojania-md
      February 26, 2025 - standard or some other widely recommended intervention like with medication reconciliation, rapid response teams … When I went from the first edition in 2007 to the second edition in 2011, there was a massive change … Here were the things that were very, very different from the early years to the middle years of the safety … I'm wondering if fundamentally we do need to hunker down and say, either we will do deep cultural change … I know one of the reasons that you wanted to start PSNet in the first place is that the nature of the

2237. Premature Closure: Was It Just Syncope? | PSNet
      psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
      February 10, 2021 - Finally, the physician failed to appreciate the high-risk nature of anticoagulation, especially in the … In the current case, although neuroimaging (CT) was ordered, the clinician did not review the results … Bradycardia and the history of syncope while exercising likely primed the clinician to view the case … Approach to Improving Safety and Systems Change Needed To help clinicians avoid similar errors, hospitals … Case The Commentary Background Approach to Improving Safety and Systems Change Needed Conclusion

2238. Effects of work shift or shift length on radiation safety perception. | PSNet
      psnet.ahrq.gov/issue/effects-work-shift-or-shift-length-radiation-safety-perception
      August 23, 2023 - View more articles from the same authors. … January 27, 2016 Understanding and confronting our mistakes: the epidemiology of error … September 16, 2020 The Psychological Safety Scale of the Safety, Communication, Operational … , Reliability, and Engagement (SCORE) survey: a brief, diagnostic, and actionable metric for the ability … September 9, 2020 Increased patient safety-related incidents following the transition

2239. FDA 101: How to Use the Consumer Complaint System and MedWatch. | PSNet
      psnet.ahrq.gov/issue/fda-101-how-use-consumer-complaint-system-and-medwatch
      February 15, 2024 - Fact Sheet/FAQs FDA 101: How to Use the Consumer Complaint System and MedWatch. … Citation Text: FDA 101: How to Use the Consumer Complaint System and MedWatch. … provides information for consumers about how to report adverse drug events and product complaints to the … US Food and Drug Administration (FDA) through the Consumer Complaint Reporting system and MedWatch … February 10, 2021 Using ventilator splitters during the COVID-19 pandemic--letter to

2240. Condition concern: an innovative response system for enhancing hospitalized patient care and safety. | PSNet
      psnet.ahrq.gov/issue/condition-concern-innovative-response-system-enhancing-hospitalized-patient-care-and-safety
      April 24, 2018 - View more articles from the same authors. … This commentary describes the design, launch, and impact of a program that enabled patients and families … 7 XML Endnote tagged PubMedId RIS Download Citation Related Resources From the … January 14, 2011 Medication safety in the ambulatory chemotherapy setting. … November 23, 2016 Bringing change-of-shift report to the bedside: a patient- and family-centered