Results

Total Results: 3,566 records

Showing results for "the change teams".

2821. Pending studies at hospital discharge: a pre-post analysis of an electronic medical record tool to improve communication at hospital discharge. | PSNet
      psnet.ahrq.gov/issue/pending-studies-hospital-discharge-pre-post-analysis-electronic-medical-record-tool-improve
      September 16, 2020 - View more articles from the same authors. … The introduction of a tool that automatically generates a list of studies pending at discharge improved … 7 XML Endnote tagged PubMedId RIS Download Citation Related Resources From the … June 21, 2016 Development of an instrument to measure the unintended consequences of … August 21, 2015 Patient identification errors: the detective in the laboratory.

2822. Linking acknowledgement to action: closing the loop on non-urgent, clinically significant test results in the electronic health record. | PSNet
      psnet.ahrq.gov/issue/linking-acknowledgement-action-closing-loop-non-urgent-clinically-significant-test-results
      July 02, 2019 - in the electronic health record. … Although the vast majority of providers used the tool, many did not find that it was helpful for any … in the electronic health record. … the United States. … Writing the wrong.

2823. Contributors to diagnostic error or delay in the acute care setting: a survey of clinical stakeholders. | PSNet
      psnet.ahrq.gov/issue/contributors-diagnostic-error-or-delay-acute-care-setting-survey-clinical-stakeholders
      May 26, 2021 - Study Contributors to diagnostic error or delay in the acute care setting: a survey … View more articles from the same authors. … A qualitative exploration across diverse acute care settings in the United States. … October 27, 2021 Organizational readiness to change as a leverage point for improving … the operating room setting in a tertiary academic center.

2824. Improving the quality of insulin prescribing for people with diabetes being discharged from hospital | PSNet
      psnet.ahrq.gov/issue/improving-quality-insulin-prescribing-people-diabetes-being-discharged-hospital
      November 16, 2022 - View more articles from the same authors. … then checklist forms of the guidelines. … August 5, 2020 Impact of the COVID-19 pandemic on the experiences of hospitalized patients … February 22, 2023 Safety at the time of the COVID-19 pandemic: how to keep our oncology … August 2, 2015 Strategies for Ensuring the Safe Use of Insulin Pens in the Hospital.

2825. Effect of promoting high-quality staff interactions on fall prevention in nursing homes: a cluster-randomized trial. | PSNet
      psnet.ahrq.gov/issue/effect-promoting-high-quality-staff-interactions-fall-prevention-nursing-homes-cluster
      July 13, 2010 - View more articles from the same authors. … Falls represent a significant cause of patient injury in the hospital setting, and evidence suggests … In this cluster-randomized trial across 24 nursing homes, researchers examined the impact of a staff … They found that the training intervention had no effect on the success of the program. … July 2, 2009 Optimizing Pediatric Patient Safety in the Emergency Care Setting.

2826. Perceptions of U.S. and U.K. incident reporting systems: a scoping review. | PSNet
      psnet.ahrq.gov/issue/perceptions-us-and-uk-incident-reporting-systems-scoping-review
      January 19, 2022 - View more articles from the same authors. … This systematic review contrasts barriers reported by providers and staff in the US and the UK. … healthcare teams. … ethical and legal consequences of medical errors: insights from the RaDonda Vaught case using the jigsaw … environment, the emotions experienced, and the impact on patient safety.

2827. Bracing for the storm: one health care system's planning for the COVID-19 surge. | PSNet
      psnet.ahrq.gov/issue/bracing-storm-one-health-care-systems-planning-covid-19-surge
      July 22, 2020 - Commentary Bracing for the storm: one health care system's planning for the COVID … Bracing for the storm: one health care system's planning for the COVID-19 surge. … This article describes the implementation of the University of Washington Medicine’s COVID-19 surge … Bracing for the storm: one health care system's planning for the COVID-19 surge. … psychological safety of healthcare workers July 8, 2020 Safety at the time of the

2828. Long-term care nurses' experiences with patient safety incident management: a qualitative study. | PSNet
      psnet.ahrq.gov/issue/long-term-care-nurses-experiences-patient-safety-incident-management-qualitative-study
      March 24, 2021 - View more articles from the same authors. … 7 XML Endnote tagged PubMedId RIS Download Citation Related Resources From the … March 24, 2021 Not overstepping professional boundaries: the challenging role of nurses … November 10, 2021 Implementation of participatory organizational change in long term … August 19, 2020 Still Failing the Frail.

2829. Fire in the Hole!—An OR Fire | PSNet
      psnet.ahrq.gov/web-mm/fire-hole-or-fire
      August 03, 2017 - After resecting the segment of the colon where the tumor was located, the surgeon realized that he had … The laceration was located and sutured without difficulty, and the decision was made to irrigate the … None of the OR staff noticed that in the course of setting up the irrigation equipment, the circulating … As the procedure continued, the bag of saline began to drip directly into the power inverter. … The scrub nurse activated the overhead lights, grabbed the fire extinguisher near the room entrance,

2830. Diagnostic Failure: The Growing Deficit | PSNet
      psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit
      June 01, 2005 - On the afternoon of the first hospital day, the patient complained of right arm numbness and weakness … The nurse called the hospitalist to relay the new symptoms of arm weakness, along with her assessment … The hospitalist asked the nurse to call for a neurology consultation and told the nurse that he would … The hospitalist had not yet evaluated the patient in person, and the neurology consultant also had not … Cognitive debiasing 2: impediments to and strategies for change.

2831. In Conversation With... Georgia Galanou Luchen, Pharm. D. | PSNet
      psnet.ahrq.gov/perspective/conversation-georgia-galanou-luchen-pharm-d
      October 24, 2021 - provides the review, through to the collaboration between the pharmacist and the nurse or the physician … Ensure that they understand why a medication change was made to their treatment. … specific provider’s office or mak[ing] an internal change to the system or process. … There is a push for regulatory change right now in recognizing pharmacists as providers and reimbursement … Improving medication safety in community pharmacy: Assessing risk and opportunities for change. 2009.

2832. In Conversation with...Eric Coleman, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-witheric-coleman-md-mph
      December 01, 2007 - EC: The model was designed for the initial encounter to take place between the patient and the coach … Depending on the part of the country that the hospital is located in and the level of competitiveness … All of a sudden this puts the financial incentive clearly in the forefront in the minds of the hospital … Patients who leave the hospital with a new diagnosis or new medications are asked to change their established … case.( 12 ) One of the most challenging aspects of improving care transitions will be to change the

2833. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33564/psn-pdf
      March 15, 2025 - Spurred by the 2009 federal HITECH Act and the accompanying Meaningful Use program, now known as the … quantity of the medication in the correct form. … Administration: the medication must be received by the correct person and supplied to the correct patient … at the right time in the right dosage. … part of the ordering clinician.

2834. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49623/psn-pdf
      March 01, 2011 - The senior nurse immediately stopped the CRRT machine and questioned the new graduate nurse caring for … the patient. … Before the new bags arrived and the CRRT could be restarted, the patient deteriorated and was taken back … Although the nurse's error in setting up the CRRT machine was not the direct cause of the patient's death … The Future of Nursing: Leading Change, Advancing Health.

2835. Electrocardiogram Results: ***READ ME*** | PSNet
      psnet.ahrq.gov/web-mm/electrocardiogram-results-read-me
      May 01, 2019 - The computer readout of the ECG stated, "****ACUTE MI****" and cited the ST elevations. … Fortunately, the patient survived, although the size of her infarct (i.e., the volume of irreversibly … 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. … have immediately ordered a repeat ECG while informing the attending physician about the change in symptom

2836. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33698/psn-pdf
      August 01, 2010 - That's the approach we've taken—really putting the problem in the hands of the people engaged in doing … the work. … So the concept of actually putting these tools in the hands of people who do the work, much in the way … By that, I mean use of evidence and the reluctance to change without strong data. … The problem at the start is that the number of defects is overwhelming.

2837. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49700/psn-pdf
      February 01, 2014 - However, given the physician's initial response, the nurse did not notify the physician about these additional … of the NSVT. … overemphasized.(7) Nursing units and health care teams that care for high-risk patients (such as the … Frequent ACLS drills and the use of rapid response teams have value and are used in many hospitals. … despite several interventions, including use of automated external defibrillators and rapid response teams

2838. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33858/psn-pdf
      May 01, 2018 - of medicine walked the earth in the 1800s. … JH: Well, you have to give me the parameters of the question and what preconditions I'm allowed to change … We had to deal with the state of the art that existed at the time HITECH was passed. … opposed to cloud-hosted, mobile-friendly subscription models that you could on a monthly basis decide to change … It will never be solved because every year the risks will change and you'll have to put in new mitigations

2839. Are We Pushing Graduate Nurses Too Fast? | PSNet
      psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast
      November 16, 2022 - The senior nurse immediately stopped the CRRT machine and questioned the new graduate nurse caring for … the patient. … Before the new bags arrived and the CRRT could be restarted, the patient deteriorated and was taken back … Although the nurse's error in setting up the CRRT machine was not the direct cause of the patient's death … The Future of Nursing: Leading Change, Advancing Health.

2840. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838972/psn-pdf
      October 27, 2022 - By the time the nurse came to the bedside to change the patient’s urine-soaked bed pads and sheets, the … The nursing staff was unable to de-escalate the contentious situation and the patient insisted on “leaving … The charge nurse was unaware of these events until the on-call physician contacted the unit for more … patient, and frustrations from either the patient, the staff, or both. … Had this process happened in the current case, the patient may have considered staying in the hospital