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Showing results for "the change teams".

2301. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room | PSNet
      psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
      July 28, 2021 - In the preoperative holding area, the anesthesia team took the patient’s history and performed a brief … The procedure was discussed with the patient and her daughter, and they agreed to proceed with the same … consultation teams were unremarkable. … By the time the medication has reached the patient, several healthcare personnel have checked that the … This approach verifies the drug as well as the concentration in the vial.

2302. Tacit Handover, Overt Mishap | PSNet
      psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
      August 01, 2006 - The patient was placed on the OR schedule for the following day. … the day, including the catheter removal, so all of them were aware of the plan. … Unfortunately, because of prolonged surgeries, the case was pushed to the end of the day. … the drain while the patient was awake in the preoperative area. … testing of a model for insurer-driven, large-scale multicenter simulation training for operating room teams

2303. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33818/psn-pdf
      November 01, 2016 - And I had not appreciated the scale of the work, the ability to move from the research into scaling … RW: Do you have a sense of the trajectory of the field? … The job has become much more complex given the aging of the population, the growing burden of chronic … It used the hub of the University of New Mexico to support primary care providers out in the community … When we think about some of the most important health care problems in the United States, including the

2304. Discharge Fumbles | PSNet
      psnet.ahrq.gov/web-mm/discharge-fumbles
      September 09, 2009 - The patient presented to the ED the following day with mental status changes. … In addition to the number of medications, the type of drug is also important. … patient actually receive the document.( 5 ) This often happens because the hospital sends the letter … On the other hand, if the diarrhea is picked up early and the patient responds to treatment, it will … Same Author(s) Using Medical Emergency Teams to detect preventable adverse events.

2305. The Other Side | PSNet
      psnet.ahrq.gov/web-mm/other-side
      May 01, 2007 - The trainee informed the attending that he had just reviewed the chart and learned that the positive … The next day, the Chief of Pathology called the trainee to inquire about the case. … teams. … The surgeon did not inform the patient of the error. … January 18, 2013 Teamwork and team performance in multidisciplinary cancer teams: development

2306. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74713/psn-pdf
      January 26, 2022 - When the morning shift started, the new nursing assistant called the team to bedside as the patient … , fatal toxicity is also on the rise.1 In 2012, the Joint Commission released the most common causes … In the event an opioid overdose is suspected, addressing the airway and ventilation is of the highest … A patient whose pain is not responding to repeated dosing of opioids may need a change in strategy. … Treatment teams should consider requesting a regional block from the Anesthesiology service and the

2307. When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication | PSNet
      psnet.ahrq.gov/web-mm/when-looks-arent-all-they-appear-be-medication-error-uncommon-indication
      July 02, 2019 - effects with unintended thioridazine further increased her risk of QT prolongation. 13   Systems Change … It also did not require the ordering provider to specify the indication for therapy.  … process are effective in capturing the prescriber’s attention and getting them to change a prescription … that thioridazine is a look-alike sound-alike medication and to include the change in naming convention … The Effect of Thioridazine Hydrochloride and Chlorpromazine on the Electrocardiogram. 

2308. Burnout | PSNet
      psnet.ahrq.gov/primer/burnout
      November 20, 2024 - not classified as a medical condition. 1 The most accepted definition from the 11 th Revision of the … The studies have highlighted the important role of systems issues as impacting the development of burnout … Association 12 has been very active in educating its physician membership and in supporting culture change … The common thread across these efforts is the focus on system-level change. … pandemic which can lead to significant culture change which can in turn impact burnout. 16 , 19,20 Peter

2309. Patient Safety During Hospital Discharge | PSNet
      psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
      April 01, 2018 - first post-hospitalization appointment ( 5 ), and one-third of tests recommended by inpatient teams … be reviewed daily by care teams. … dietitian, the nurse, the doctor, and the work clerk, etc." … What have we learned from that measure that is generalizable to our efforts to change the payment and … measurement for quality improvement from reasonable measurement for accountability and incentivizing change

2310. Miscommunication in the OR Leads to Anticoagulation Mishap | PSNet
      psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap
      May 08, 2019 - The patient's identity, the operation, the surgical site, and the anesthesia plan were verified. … The surgeon told the anesthesiologist that the patient would benefit from epidural analgesia continued … The anesthesiologist was new to the hospital and unfamiliar with the postoperative management of patients … The patient was started on enoxaparin per the surgeon's order. … checklist into the workflow of OR teams, conflicting priorities of various stakeholders responsible

2311. Wrong-side Bedside Paravertebral Block: Preventing the Preventable | PSNet
      psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable
      August 10, 2019 - The fall occurred as she attempted to sit down in the bathroom and missed the toilet, falling backwards … The patient was admitted to the medical-surgical ward. … The anesthesiologist performed the block on the patient while she was in her bed. … On review of the case, it was noted that the personnel carrying out the procedure at the bedside had … A team or block time-out should be repeated if there is any delay or distraction, change in patient position

2312. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33560/psn-pdf
      June 15, 2024 - These include: Disclosure of all harmful errors An explanation as to why the error occurred How the … error and its effects on the patient's health. … of information that should be disclosed and how to explain the error to the patient. … these programs, and the Agency for Healthcare Research and Quality has developed the Communication … in court but the effect on malpractice lawsuits has been mixed.

2313. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest | PSNet
      psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
      April 01, 2008 - the tip of the catheter was in the lower half of the superior vena cava, he closed the wound.  … Realizing the seriousness of the child’s bleeding condition, he alerted the patient's surgeons and the … One of the primary roles of the surgical team is to mitigate risk once the risks and benefits of the … April 1, 2008 WebM&M Cases Critical Order Set Change … efficacy of rapid response teams.

2314. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.25_slideshow.ppt
      July 01, 2003 - As there was no DNR form in the chart, the nurse called a code and CPR was initiated. … The code team found the intern’s initial assessment, which stated the patient’s preference for no resuscitation … Case (cont.): Code Status Confusion The resident had discussed the case briefly with the intern (including … her interpretation that the patient wished to be a DNR), but neither the resident nor the attending … the events of the previous night.

2315. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49671/psn-pdf
      November 01, 2012 - The computer readout of the ECG stated, "****ACUTE MI****" and cited the ST elevations. … The case raised concerns about the review of ECGs routinely performed in the hospital setting and often … The first error was that the person performing the ECG (i.e., the nursing assistant) did not understand … the terminology or the implication of the computer-generated diagnostic statement. … would have immediately ordered a repeat ECG while informing the attending physician about the change

2316. Clinical Decision Support Systems | PSNet
      psnet.ahrq.gov/primer/clinical-decision-support-systems
      December 15, 2024 - Background The promised benefits of health information technology rest in large part on the ability of … the optimal antibiotic choice given specific microbiologic data) or diagnostic tests (e.g., the best … Clinical decision support systems are increasingly being used to provide support for interdisciplinary teams—for … PCCDS) refers to decision support systems that support individual patients, caregivers, and health care teams … The advent of advanced analytic methodologies for large, complex data sets and the development of machine

2317. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33689/psn-pdf
      October 01, 2009 - people understood that health care could cause harm, this concern was too inchoate to generate real change … attention and resources required for change. … Organizational Change in the Face of Highly Public Errors-I. … Organizational Change in the Face of Highly Public Errors-II. The Duke Experience. … https://psnet.ahrq.gov//#ref10back https://psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience

2318. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49419/psn-pdf
      October 01, 2003 - As the trainee prepared to make an incision on the left side of the vulva, the attending surgeon stopped … The trainee informed the attending that he had just reviewed the chart and learned that the positive … The next day, the Chief of Pathology called the trainee to inquire about the case. … teams. … The surgeon did not inform the patient of the error.

2319. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33795/psn-pdf
      November 01, 2015 - The Agency for Healthcare Research and Quality (AHRQ), under the leadership of the late Dr. … the release of the IOM report. … In the early days of the patient safety movement, a dominant challenge was the relative dearth of high … from the epidemiology of adverse events to the benefits of barcoding to best practices in the use of … In an editorial I wrote at the time of PSNet's launch (2), I reflected on the breadth of the field,

2320. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.194_slideshow.ppt
      March 01, 2009 - Case: All in the History (2) In the code room, the physician found an elderly man with no pulse, no … Case (cont.): All in the History (5) The ED physician contacted the team that would be managing the patient … .): All in the History (6) The admitting ICU team evaluated the patient and agreed with the initial … The patient was taken to the ICU. … handoff between the ED and inpatient teams should be brief but standardized to include the pertinent