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psnet.ahrq.gov/node/33799/psn-pdf
January 01, 2015 - to face the demands of the job, and unable to engage with others. … In the study, published in late 2014, the investigators propose that the linkage
between burnout and … The Swiss ICU study, which enrolled 1425 nurses and physicians on 54 ICU teams from 48 different
hospitals … These results
support the idea that the odds of achieving the so-called Triple Aim (improving the patient … of the Triple Aim that it should be added to the model, changing it to the
Quadruple Aim.
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psnet.ahrq.gov/web-mm/stroke-error
February 01, 2016 - The history should center on establishing the time of symptom onset or the time the patient was last … cerebral function due to hypertension typically result in diffuse symptoms that may include headache, change … intravenous rtPA [recombinant tissue plasminogen activator].( 8 ) Pre-hospital notification of acute stroke teams … Written stroke protocols and coordinated acute stroke teams can reduce onset-to-treatment times and facilitate … Only in the case of amputation or joint fusion at the shoulder, the examiner should record the score
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psnet.ahrq.gov/node/49579/psn-pdf
March 21, 2009 - This uncertainty may not be appreciated by admitting teams and may be
related to ED physicians overstating … A colleague of mine has said that ED physicians are "sensitive," while admitting teams aim to be
"specific … This cultural chasm can contribute to admitting
teams' mistrust of ED ability, judgment, or professionalism … A consequence of admitting teams not fully appreciating the ED approach to establishing the diagnosis … The handoff between the ED and inpatient teams should be brief but standardized to include the
pertinent
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.281_slideshow.ppt
October 01, 2012 - Two days later, the bump was larger with a small amount of pus at the center. … The pediatrician incised the lesion, expressed pus, and cultured the fluid. … Deep tissue debridement of the hip lesion was performed in the intensive care unit (ICU) because the … the pediatric patient. … 2010NCAA_Rules_Book.pdf
*
Take-Home Points
To prevent sports-related skin infections, everyone involved in sports teams
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psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
May 26, 2021 - the ICU to the inpatient floor. … When the morning shift change occurred, the morning nurse evaluated the patient and found her to be barely … are: the right patient, the right drug, the right dose, the right route, the right time, the right documentation … assess the patient’s response to the medication, or they would have recognized the patient’s change … , the right documentation, the right reason and the right response.
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psnet.ahrq.gov/web-mm/monitoring-fetal-health
September 08, 2010 - The first difference concerns the nature of the display itself. … and clear communication between the health care teams, and a common acceptance and understanding of … This complicated patient flow requires dedicated specialized teams with strong commitment to safety. … Achieving this requires open and transparent communication between the health care teams, ongoing education … Development and usability of a behavioural marking system for performance assessment of obstetrical teams
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psnet.ahrq.gov/perspective/health-care-worker-presenteeism-challenge-patient-safety
November 03, 2015 - Change Is Complex and Requires Attention to All Drivers of Health Care Worker Presenteeism
Health care … in this case the easy one. … The role played by contaminated surfaces in the transmission of nosocomial pathogens. … necessarily represent the views of AHRQ. … None of the authors has any affiliation or financial involvement that conflicts with the material presented
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psnet.ahrq.gov/node/49713/psn-pdf
June 01, 2014 - The kit
contained instructions for the procedure and the appropriate materials, including the occlusive … A process change is needed to ensure that only health care professionals who have
received adequate … and removal of
CVCs is an example of a process change that has been effective in reducing CVC-associated … Have the patient perform the
Valsalva maneuver as the last portion
of the CVC is removed. … Change the
dressing every 24 hours until the exit
site has healed.
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psnet.ahrq.gov/node/49722/psn-pdf
December 01, 2014 - The medical team was preparing the patient for discharge the
following day. … When the nurse raised the bed, unbeknownst to her, the tubing for the SCDs caught on
the bed wheel lock … the wheel and brake of the bed. … During the reenactment, the staff realized it was possible for the
tubing to catch the brake and unlock … This reactive change may be limited to just one hospital and likely
did not result in more systemic
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psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
January 01, 2023 - at the change of shift, which occurred
right after NGT placement … acute change to any of the physicians
involved in his care … at change-of-shift, led to more serious consequences from
his iatrogenic injury … the
proximal end of the tube at the tip of the patient’s nose, looping the tube behind
the patient … between the bedside and charge nurses, at
nursing change of shift, and between the nurse and supervising
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psnet.ahrq.gov/sites/default/files/2022-10/trocar_injury_final.pdf
January 01, 2022 - • After the left ovary was removed and the procedure concluded, the
patient was discharged home the … The transverse colon was adherent to the peritoneum at
the umbilicus, and the colon at this location … The initial trocar can then be
inserted at the site of the needle, or at a different site on the
abdomen … number of foams removed and
inserted during each dressing change (to ensure that the number of foams … removed equals the number of foams inserted in the previous dressing change)
-
psnet.ahrq.gov/node/838900/psn-pdf
October 27, 2022 - After the left ovary was
removed and the procedure concluded, the patient was discharged home the same … The transverse colon was adherent to the peritoneum at the
umbilicus, and the colon at this location … The initial trocar can then be
inserted at the site of the needle, or at a different site on the abdomen … number of foams
removed and inserted during each dressing change (to ensure that the number of foams … removed equals
the number of foams inserted in the previous dressing change).17 Similarly, the number
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psnet.ahrq.gov/node/73553/psn-pdf
July 28, 2021 - That’s just the beginning of the process. … The same with stroke, the same with acute MIs, the same with
delivering babies, the same with very sick … ; that the extrication of the patient took
place; that the patient was transported; and that the EMS … and to really take the care to the people. … the outcome of the patient.
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psnet.ahrq.gov/perspective/are-residency-duty-hour-rules-improving-patient-safety
April 01, 2013 - The first real policy change in 2003 limited the hours substantially in only a couple of specialties. … hours were not infrequently over 100 hours a week, an 80-hour workweek was a relatively substantive change … medicine, and family practice, it represented more of a minor rearrangement in hours than a revolutionary change … , because there simply wasn't much change in work hours or sleep. … RW : You led a now famous study that demonstrated no change in at least one way of measuring patient
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psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
January 29, 2020 - Although the positive blood culture was sent to the medical attending's inbox in the electronic health … When the mistake was recognized, the team called the patient and she was immediately readmitted to the … best approach involves weighing the probability of disease in the patient, the risks and benefits of … inpatient microbiology tests result after discharge and approximately 2% of those require follow-up or a change … First, the nurse who received the initial notification from the microbiology laboratory may not have
-
psnet.ahrq.gov/node/49799/psn-pdf
July 01, 2017 - Although the
positive blood culture was sent to the medical attending's inbox in the electronic health … When the mistake was recognized, the team
called the patient and she was immediately readmitted to the … best approach involves
weighing the probability of disease in the patient, the risks and benefits of … inpatient microbiology tests result after discharge and approximately 2% of those
require follow-up or a change … time.(20)
In this case, the reporting of the positive result from the microbiology laboratory was
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.245_slideshow.ppt
July 01, 2011 - 1
2
Source and Credits
This presentation is based on the July 2011
AHRQ WebM&M Spotlight Case
See the … in the safe management of warfarin
Recognize the risks and benefits of newer anticoagulants
3
4
Case … anticoagulated on the warfarin. … There were no changes made to any of the medications he was taking before the hospitalization, including … the warfarin.
5
6
Case: Watch the Warfarin (3)
A week later, in routine laboratory testing with
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psnet.ahrq.gov/perspective/conversation-patricia-dykes-about-ongoing-journey-prevent-patient-falls
December 18, 2024 - One of the implementation issues is that any change in practice in an acute care environment requires … In this environment, change first requires support from leadership. … Leadership by nurse managers is needed to support practice change at the bedside and to provide proper … If nothing changes, they reinforce it and change the date. … We are trying to change that message; just like you should eat well every day, you should exercise every
-
psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls
December 18, 2024 - One of the implementation issues is that any change in practice in an acute care environment requires … In this environment, change first requires support from leadership. … Leadership by nurse managers is needed to support practice change at the bedside and to provide proper … If nothing changes, they reinforce it and change the date. … We are trying to change that message; just like you should eat well every day, you should exercise every
-
psnet.ahrq.gov/perspective/conversation-anjali-joseph-phd-edac-and-molly-m-scanlon-phd-faia-facha
June 30, 2021 - KH: So, Molly, is the COVID-19 pandemic going to fundamentally change how we think about design for … If the whole unit is then designated as a COVID-19 unit, do we change the ventilation to make it a negative … One big change that is happening is the role of the waiting areas in these clinics and outpatient areas … What would you change to protect patients? … Hopefully post-COVID-19 we will not only be thinking about what needs to change in our infectious disease