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Showing results for "the change teams".

2441. Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery. | PSNet
      psnet.ahrq.gov/issue/prevention-3-never-events-operating-room-fires-gossypiboma-and-wrong-site-surgery
      February 10, 2012 - Review Prevention of 3 "never events" in the operating room: fires, gossypiboma, … Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery. … View more articles from the same authors. … April 30, 2014 The recurring problem of retained swabs and instruments. … July 16, 2013 Surgical never events in the United States.

2442. Improving handoffs in the emergency department. | PSNet
      psnet.ahrq.gov/issue/improving-handoffs-emergency-department
      July 19, 2017 - Improving handoffs in the emergency department. … View more articles from the same authors. … Improving handoffs in the emergency department. … and emergency department staff in the deteriorating patient. … November 13, 2013 'The ABC of Handover': impact on shift handover in the emergency department

2443. Wrong site surgery near misses and actual occurrences. | PSNet
      psnet.ahrq.gov/issue/wrong-site-surgery-near-misses-and-actual-occurrences
      November 30, 2012 - View more articles from the same authors. … testing of a model for insurer-driven, large-scale multicenter simulation training for operating room teams … April 30, 2014 The pain of wrong site surgery. … September 15, 2010 Determining the state of knowledge for implementing the Universal … Protocol recommendations: an integrative review of the literature.

2444. Principles of pediatric patient safety: reducing harm due to medical care. | PSNet
      psnet.ahrq.gov/issue/principles-pediatric-patient-safety-reducing-harm-due-medical-care
      May 22, 2019 - View more articles from the same authors. … This updated policy statement from the American Academy of Pediatrics reviews the epidemiology of … The article emphasizes the responsibility of pediatricians to be familiar with patient safety concepts … The article concludes with a series of specific recommendations for advancing the science of patient … January 11, 2017 Principles supporting dynamic clinical care teams: an American College

2445. From blaming to learning: re-framing organisational learning from adverse incidents. | PSNet
      psnet.ahrq.gov/issue/blaming-learning-re-framing-organisational-learning-adverse-incidents
      October 05, 2022 - View more articles from the same authors. … relationship between patient safety culture and the intentions of the nursing staff to report a near-miss … event during the COVID-19 crisis. … May 19, 2015 The development of the National Reporting and Learning System in England … September 1, 2011 The need for organizational change in patient safety initiatives.

2446. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33635/psn-pdf
      July 01, 2006 - psnet.ahrq.gov/perspective/conversation-withallan-frankel-md https://psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-i-dana-farber-cancer-institute … interested in being innovators or early adopters; you put so much energy into trying to make them change … in their organizations to turn it into real actions that change the environment. … I say that because if you want to be able to make system-wide change, it's very nice to have the control … groups become more powerful and siloed, they can get to a point where it's impossible to make effective change

2447. Cognitive Overload in the ICU | PSNet
      psnet.ahrq.gov/web-mm/cognitive-overload-icu
      June 01, 2005 - Simulation has long been used to train teams to work more effectively together, and those methods are … Take-Home Points In the complex ICU environment, teams must recognize that their work is cognitively … With effective approaches to balancing and sharing tasks, well-functioning teams can help to reduce the … Effective teams are built through effective training, including the use of simulation methods. … Teams should learn how to distribute cognitive loads so as to complement each other, offload tasks when

2448. Management of Cardiac Arrest in Unconventional Locations. | PSNet
      psnet.ahrq.gov/web-mm/management-cardiac-arrest-unconventional-locations
      June 14, 2023 - 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 of … Resuscitation team roles and responsibilities: in-hospital cardiopulmonary arrest teams.

2449. Opioid Safety | PSNet
      psnet.ahrq.gov/primer/opioid-safety
      December 15, 2024 - The medical literature is rife with such examples; the most recent one is that of opioid pain medications … This Primer will describe the nature of the opioid epidemic as a patient safety problem, discuss the … safety standpoint, the primary issue is the extraordinarily high rate of opioid prescribing in the United … It now appears clear that during the 1990s and 2000s, the health care system promoted the overuse of … The patient safety field was slow to recognize the burgeoning epidemic.

2450. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49553/psn-pdf
      January 01, 2008 - The Commentary The case history that forms the basis for this commentary illustrates several of the … Studies have shown that trained phlebotomists or blood culture teams have fewer contaminated blood cultures … able to reduce blood culture contamination rates by utilizing trained phlebotomists or blood culture teams … resident physicians to obtain these specimens.(5-7,21) Laboratory-trained phlebotomists and blood culture teams … Phlebotomy teams reduce blood-culture contamination rate and save money.

2451. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836840/psn-pdf
      April 22, 2021 - that a patient had refused the medication, the educator met with the patient. 23 Context of the Innovation … At the time of the start of the initiative, the VTE Collaborative found that only 33% of patients were … missed dose of VTE due to patient refusal (5.9% to 3.4%) while the patient refusal rate did not change … in the control group.24 Innovation Patient Safety Focus The focus of the innovation is the prevention … and creating treatment plans Incentives for improved provider performance A bottom-up approach to change

2452. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33728/psn-pdf
      May 01, 2012 - You can intervene in real time to change the dose and stop or modify the drug dosage. … Basically, even if you combine the AHRQ PSIs and the voluntary reporting system—they missed 90% of the … DC: In an analysis conducted at one of the hospitals looking at the sensitivity and specificity of the … The cascading of events that occurred in the Medicare study—more than a quarter of the patients had … DC: When we did this at LDS Hospital in the early 1990s, 50% of the time the care team didn't know that

2453. Retained Surgical Items: Definition and Epidemiology. | PSNet
      psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
      September 15, 2024 - incisional closure, because the operation isn’t over until the patient leaves the OR. … exhausted the ability to find it in the OR. … closure, even if the patient is still in the OR under anesthesia. … of removing the object exceeds the risk of leaving it where it is. … to the patient the presence of the unretrieved device or device fragment and (2) keeps a record of cases

2454. Isolated Clot, Real Error | PSNet
      psnet.ahrq.gov/web-mm/isolated-clot-real-error
      December 01, 2013 - That afternoon, the intern checked the results and noted the first line of the final result stated "Positive … The next day on rounds, the intern reported to the rest of the ICU team that the ultrasound was positive … The team recognized the error and disclosed it to the patient and family. … indicated for provoked VTE or in patients who require indefinite anticoagulation and where testing will not change … August 31, 2022 WebM&M Cases Critical Order Set Change

2455. Breathe Easy: Safe Tracheostomy Management | PSNet
      psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management
      June 07, 2023 - 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, allowing … During the first 5–7 days after tracheostomy, before the stoma is well formed, dislodgement of the tube … secure the airway.

2456. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49582/psn-pdf
      April 01, 2009 - The neonatologist opted to remove the catheter. … When the RN started to remove the PICC, it broke, leaving approximately 7 cm in the patient. … of specialized PICC teams to insert them. … The child described in the present case required surgery for removal of the PICC fragment. … outweighs the benefit of changing the dressing.

2457. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866847/psn-pdf
      September 25, 2024 - And, when we do have an event of harm, the role of the leader is to help the organization pick itself … , the day-to-day words and actions of the organization. … These kinds of leading and real-time indicators are the right focal point in the effort to change outcomes … The practices of organizations leading the way will hopefully become the tipping point for making the … The CMS structural measure is a push in the right direction and in the right way. 

2458. Medication Mix-Up Leads to Patient Death | PSNet
      psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
      July 08, 2022 - When the barcode on the jug of dialysis liquid did not scan, the nurse called the hospital pharmacy for … The nurse successfully scanned the new barcode label and administered about 8 ounces of the dialysis … The ICU physician who ordered the polyethylene glycol solution said that the patient had to take the … Given that health care professionals are highly trained and accustomed to working in teams, they develop … a hand-off, where one individual hands off a medication to another for administration, either at a change

2459. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49732/psn-pdf
      May 01, 2015 - timing of the antibiotic administration was appropriate (the patient was in the ED for which the guideline … In order to maximize timely adherence to the bundle, institutions have created sepsis teams. … facilitate the ordering of the bundle elements. … When the patient's chart is subsequently entered by a nurse or other provider, the alert stating the … Factors to Identify Sepsis-Related Organ Dysfunction Hypotension with SBP 40 mm Hg from baseline Acute change

2460. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/857259/psn-pdf
      November 30, 2023 - When the barcode on the jug of dialysis liquid did not scan, the nurse called the hospital pharmacy … The nurse successfully scanned the new barcode label and administered about 8 ounces of the dialysis … The ICU physician who ordered the polyethylene glycol solution said that the patient had to take the … Given that health care professionals are highly trained and accustomed to working in teams, they develop … a hand-off, where one individual hands off a medication to another for administration, either at a change