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Showing results for "the change teams".

2641. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837660/psn-pdf
      July 08, 2022 - The patient completed the consent process with both the pulmonologist and the anesthesiologist before … Uncertain of the etiology, the team reached out to the family in the waiting room. … After review of his history by the team, the patient was taken into the bronchoscopy suite for the biopsy … When the scope is passed via the nasal cavity, the bite block is unnecessary and the mouth can remain … If the patient does not recognize the significance of the event, it is unlikely that the problem will

2642. A Picture Speaks 1000 Words | PSNet
      psnet.ahrq.gov/web-mm/picture-speaks-1000-words
      July 16, 2015 - The case was reviewed in light of the tragic outcome. … study with the results on the text report of the prior dissection. … a change in an existing disease state. … The culprit in this case was not the security system, it was the workaround and the failure to address … Department of Veterans Affairs Chief Resident in Quality and Patient Safety Program: a model to spread change

2643. Spotlight Case September 2006 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.134_slideshow.ppt
      September 01, 2006 - verbal signout List Kotter’s 8 steps to leading change Case: Triple Handoff An 83-year-old … X-ray of Pneumothorax Kotter's 8-Step Approach to Leading Change Establish urgency Form a powerful … short-term wins Consolidate improvements, creating more change Institutionalize new approach Kotter … Leading change: why transformation efforts fail. Harv Bus Rev. March 1995. … effectiveness of the sign-out process A change framework can be an effective strategy to implementing

2644. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60362/psn-pdf
      April 13, 2018 - the innovation. … with the medical center, where the vast majority of the state's high-risk pregnancy services, maternal-fetal … Key elements of the program include the following: Call center: The call center, staffed by women's … The medical center, the Arkansas Department of Human Services, and the Arkansas Medical Society united … The future of maternal mortality and morbidity can be change with continued development of programs

2645. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33856/psn-pdf
      April 01, 2018 - the inpatient to the subsequent care team—whether it be the patient's outpatient providers or providers … first post-hospitalization appointment (5), and one-third of tests recommended by inpatient teams for … should be reviewed daily by care teams. … , while the system may have successfully treated the acute cause of hospitalization, the hospitalization … from the hospital.

2646. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33880/psn-pdf
      May 01, 2019 - The dearth of data and information on patient safety in the EMS setting is linked to the absence of … nonfatigued.(10) The risk of injury is also high among EMS crews in which the teammates lack experience … The greatest opportunity will come by improving organizational safety culture.(14) The wide variation … management in EMS (18); (ii) the Strategy for a National EMS Culture of Safety (22); and (iii) the … Teammate familiarity, teamwork, and risk of workplace injury in emergency medical services teams.

2647. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841566/psn-pdf
      December 14, 2022 - Deputy Director of the Center for Clinical Standards and Quality and the Director of the Quality Measurement … National-Steering-Committee-Patient-Safety/Pages/National-Action-Plan-to-Advance-Patient-Safety.aspx https://www.who.int/teams … strategies-prevent-central-line-associated-bloodstream-infections-acute-care-hospitals-2022 is appropriate, remove them, or change … I think it will change our perception of what is quality and safe care overall and what https://pso.ahrq.gov … Another measurement change we will need to see is a shift to digital measures that come from the EMR

2648. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853902/psn-pdf
      September 27, 2023 - patient at the bedside. … The family decided to withdraw care and the patient died the following afternoon. … There was failure in the fourth step in the diagnostic process, verifying the diagnosis by ruling out … Perhaps the first indication the patient was in early sepsis was the elevated lactate level. … When an unanticipated change in clinical exam or status occurs, one should broaden the differential

2649. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning | PSNet
      psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
      January 29, 2021 - at the bedside. … The family decided to withdraw care and the patient died the following afternoon. … There was failure in the fourth step in the diagnostic process, verifying the diagnosis by ruling out … Perhaps the first indication the patient was in early sepsis was the elevated lactate level. … When an unanticipated change in clinical exam or status occurs, one should broaden the differential to

2650. Patient Safety Events Involving Opioid Dose Stacking | PSNet
      psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
      July 08, 2022 - When the morning shift started, the new nursing assistant called the team to bedside as the patient was … , 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 addition

2651. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60543/psn-pdf
      May 27, 2020 - With the next shift change, a new team took over and after a few hours, the IR nurse called asking for … When the unit nurse came in to assess the patient, the physician walked in at the same time and both … During the shift change that morning, the sign-out to the day shift nurse indicated that PICC insertion … If the telephone call occurred at the end of the shift, the nurse might have been fatigued, especially … the order, and confirm they understand the indication for the order.

2652. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.365_slideshow.ppt
      January 01, 2016 - At shift change, the patient's room was ready, but the nurse who had initially greeted him on arrival … The nurse completed the usual check-in process later in the evening but did not contact the admitting … (the third in his care so far) noted the patient was difficult to arouse. … shift-to-shift communication about admissions Establish walk rounds to facilitate handoff communication at shift change … the admitting provider for orders The treatment plan should have been communicated clearly to the patient

2653. All in the History | PSNet
      psnet.ahrq.gov/web-mm/all-history
      February 28, 2011 - 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

2654. Breakage of a PICC Line | PSNet
      psnet.ahrq.gov/web-mm/breakage-picc-line
      June 21, 2023 - 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.

2655. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33714/psn-pdf
      July 01, 2011 - the U.S. … What this does for the people doing the analysis, and for the institutions where they work, is create … The first is that if you only define it at the national level and don't specify the details necessary … up at the PSO level and to the national level, which also provides the ability to benchmark or compare … So to some extent, the increasing automation of everything has on the one hand offered the opportunity

2656. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49543/psn-pdf
      September 01, 2007 - The nurse caring for the patient misinterpreted the EMAR and gave an excessive amount of the gabapentin … The patient told the nurse that the amount of medicine given seemed to be more than she was accustomed … Although the overdosage was noted at the time, the administration of the incorrect drug (Neurontin, … the preoperative consultant's error to propagate from the outpatient to the inpatient setting. … to the pharmacist, making it impossible for the pharmacist to compare the admission orders against

2657. Second Victims: Support for Clinicians Involved in Errors and Adverse Events | PSNet
      psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
      December 15, 2024 - When a medical error or patient harm occurs, the first priority is to attend to the patient and family … responsibility, and the outcome for the patient seem to be predictive of the degree of distress clinicians … sense that the provider is traumatized by the event." … The authors speculate that the intensity of the experience and the responsiveness of the organization … Enduring the Inquisition Clinician braces for the institutional investigation, wonders about the impact

2658. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72836/psn-pdf
      January 26, 2021 - healthcare team with perspectives critical to the clinical decision-making process, but also to the … For example, the different iterations of the AHRQ Consumer Assessment of Healthcare Providers and Systems … at: 1) believing the patient role is important; 2) having the confidence and knowledge necessary to … While the programs have concluded, the PFE metrics developed for the Partnership for Patients (PfP … Shift Change Huddles/Bedside Reporting with Patients and Families 3.

2659. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49506/psn-pdf
      March 01, 2006 - The Wet Read March 1, 2006 Arenson RL. The Wet Read. PSNet [internet]. 2006. … subspecialist academic faculty reads the film again the next morning, the costs for the services may … referring physician with a clear indication of the change. … a change, the magnitude of the change, and whether it might alter care for the patient. … be made to change the culture to increase resident willingness to involve the attending.

2660. Treatment Challenges After Discharge | PSNet
      psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
      January 03, 2017 - After a urine culture was obtained in the ED, the patient was started on vancomycin and admitted to the … Intra-hospital care transitions involve two clearly defined care teams (transferring and receiving) that … Even if the transfer of care is done poorly, the patient still is in the hospital and is surrounded by … Furthermore, hospital-based care teams and primary care physicians often exist in different health care … He was admitted to the hospital with the diagnosis of severe sepsis.