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Showing results for "the change teams".

2841. Spotlight Case Hindsight Is 2020 Slides Final Revised 05.03.2024 (pdf file)
      psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_hindsight_is_2020_slides_final_revised_05.03.2024.pdf
      January 01, 2024 - – The risks and benefits were explained to the patient, and he consented. … • The patient was admitted to the intensive care unit (ICU) for close monitoring. … tendency, in the midst of uncertainty, to err on the side of action regardless of the evidence … the following:22 1. … Isolated sensory symptoms without weakness (S) • The higher the score, the more likely a “stroke mimic

2842. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33769/psn-pdf
      June 01, 2014 - defined, depending on where problems are seen to lie and where it appears to be possible to influence change … care aimed to change health care from within by facilitating partnerships among patients, families, … Patients, led to a sea change in the interaction of patients with hospitals, researchers, and other … This amounts to a great deal of change. Yet in many ways it is much less change than we would wish. … This situation has the potential to change considerably with the availability of more granular "big

2843. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49695/psn-pdf
      October 01, 2013 - After noting the patient's difficulty in walking, his mother contacted the primary team, the error was … In review of the resident's discharge note, the discharge plan for the phenytoin was clearly stated, … Lastly, the community pharmacy did not question the 500 mg TID dosing regimen. … failure of users to notice and change the inappropriate default settings termed as "technology induced … We found that a significant proportion of system-related errors resulted from physicians failing to change

2844. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49649/psn-pdf
      March 01, 2012 - The patient had lived through the Vietnam War; he and his family had come to the United States on a … boat as part of a mass exodus in the late 1970s; there was strife within the family unit, as the patient … Traditional Vietnamese values emphasize maintaining the stability of the culture and primacy of the … And, more important, did they notice a change in his behavior? … What needed to change to help him feel better?

2845. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49463/psn-pdf
      October 14, 2004 - The room change was made on the hospital's computer before the patients were physically moved. … Thus, when the nurse checked the computer, it showed that Mr. … Next, the nurse failed to correctly identify the patient when she began the medication administration … As in the case of CPOE, the number of hospitals that have successfully implemented bar coding into the … a patient location change to be made in an already occupied bed.

2846. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49854/psn-pdf
      February 01, 2019 - 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.

2847. The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety | PSNet
      psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
      October 01, 2009 - 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. … Perspective Organizational Change in the Face of Highly Public Errors—II. … Change in the Face of Highly Public Errors—I.

2848. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33661/psn-pdf
      December 01, 2007 - from the census as they clean out the room. … hospital's desire to clear the bed than by the availability of caregivers to participate in the discussion … Patients who leave the hospital with a new diagnosis or new medications are asked to change their established … On the receiving end, PCPs often first learn of the hospitalization when the patient calls in with a … case.(12) One of the most challenging aspects of improving care transitions will be to change the system

2849. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60169/psn-pdf
      March 25, 2020 - The solution was labeled with the contents, date and time and placed in the warmer.  … When the nurse went to retrieve the solution, it was missing from the warmer. … However, they do constitute near miss events that should serve as a catalyst to change institutional … Systems Change Needed/Quality Improvement Approach Adequate labelling and storage of irrigation solutions … Communication about relevant matters needs to be repeated whenever there is a change of staff in the

2850. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.230_slideshow.ppt
      December 01, 2010 - is based on the December 2010 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov … Appreciate the importance of early skin assessment and the challenges of pressure ulcer identification … hours before being transferred to an inpatient room during the change in nursing shifts at 7:00 AM. … Due to a mechanical problem with one of the beds, the patient was kept in the same bed she had been in … Medicare’s decision to withhold payment for hospital errors: the devil is in the details.

2851. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33748/psn-pdf
      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

2852. COVID-19 and Dentistry: Challenges and Opportunities for Providing Safe Care | PSNet
      psnet.ahrq.gov/primer/covid-19-and-dentistry-challenges-and-opportunities-providing-safe-care
      February 24, 2022 - to the high risk for dental personnel teams becoming exposed and transmitting the virus to other patients … vicinity of the patient’s chair (but not behind the DHCP) while the patient is actively undergoing, … in an effort to facilitate the use of tele-dentistry during the pandemic. … pandemic may require dentists to change their workflows 62,63 or re-configure their clinic layouts … ADA asks CDC to change dental guidance on COVID-19. DentistryIQ . May 6, 2020.

2853. Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. | PSNet
      psnet.ahrq.gov/issue/root-cause-analysis-reports-help-identify-common-factors-delayed-diagnosis-and-treatment
      October 24, 2018 - View more articles from the same authors. … This study from the Veterans Affairs (VA) system reveals the clinical impact of inadequate care processes … By analyzing 111 root cause analyses of diagnostic error cases in the outpatient setting, the authors … Department of Veterans Affairs Chief Resident in Quality and Patient Safety Program: a model to spread change … reduce hazards in the testing process in primary care.

2854. Impact of the COVID-19 pandemic on the experiences of hospitalized patients: a scoping review. | PSNet
      psnet.ahrq.gov/issue/impact-covid-19-pandemic-experiences-hospitalized-patients-scoping-review
      September 21, 2022 - Review Impact of the COVID-19 pandemic on the experiences of hospitalized patients … Impact of the COVID-19 pandemic on the experiences of hospitalized patients: a scoping review. … Due to the infectious and deadly nature of COVID-19, heath care facilities were forced to change many … Impact of the COVID-19 pandemic on the experiences of hospitalized patients: a scoping review. … September 21, 2022 Predictive power of the "trigger tool" for the detection of adverse

2855. Using event reports in real-time to identify and mitigate patient safety concerns during the COVID-19 pandemic. | PSNet
      psnet.ahrq.gov/issue/using-event-reports-real-time-identify-and-mitigate-patient-safety-concerns-during-covid-19
      March 23, 2022 - View more articles from the same authors. … September 29, 2009 COVID-19: the dark side and the sunny side for patient safety. … : the WHO Surgical Safety Checklist and the COVID-19 pandemic: recommendations for content and implementation … January 27, 2021 In the eye of the storm: the role of the pharmacist in medication safety … December 16, 2020 COVID-19: the dark side and the sunny side for patient safety.

2856. Evolving factors in hospital safety: a systematic review and meta-analysis of hospital adverse events. | PSNet
      psnet.ahrq.gov/issue/evolving-factors-hospital-safety-systematic-review-and-meta-analysis-hospital-adverse-events
      February 02, 2022 - View more articles from the same authors. … 7 XML Endnote tagged PubMedId RIS Download Citation Related Resources From the … June 8, 2022 Development and usability testing of the Agency for Healthcare Research … May 25, 2022 Advanced medication reconciliation: a systematic review of the impact on … November 16, 2022 Organizational readiness to change as a leverage point for improving

2857. Assessing controlled substance prescribing errors in a pediatric teaching hospital: an analysis of the safety of analgesic prescription practice in the transition from the hospital to home. | PSNet
      psnet.ahrq.gov/issue/assessing-controlled-substance-prescribing-errors-pediatric-teaching-hospital-analysis-safety
      August 02, 2010 - safety of analgesic prescription practice in the transition from the hospital to home. … safety of analgesic prescription practice in the transition from the hospital to home. … The journal of pain : official journal of the American Pain Society. 2009;10(2):160-6. doi:10.1016/j.jpain … The journal of pain : official journal of the American Pain Society . 2009; 10 (2) :160-6 . … safety of analgesic prescription practice in the transition from the hospital to home.

2858. Consensus statement on effective communication of urgent diagnoses and significant, unexpected diagnoses in surgical pathology and cytopathology from the College of American Pathologists and Association of Directors of Anatomic and Surgical Pathology. | PSNet
      psnet.ahrq.gov/issue/consensus-statement-effective-communication-urgent-diagnoses-and-significant-unexpected
      November 16, 2022 - urgent diagnoses and significant, unexpected diagnoses in surgical pathology and cytopathology from the … urgent diagnoses and significant, unexpected diagnoses in surgical pathology and cytopathology from the … View more articles from the same authors. … urgent diagnoses and significant, unexpected diagnoses in surgical pathology and cytopathology from the … January 8, 2016 Principles supporting dynamic clinical care teams: an American College

2859. Adverse events in intensive care and continuing care units during bed-bath procedures: the prospective observational NURSIng during critical carE (NURSIE) study. | PSNet
      psnet.ahrq.gov/issue/adverse-events-intensive-care-and-continuing-care-units-during-bed-bath-procedures
      March 05, 2025 - View more articles from the same authors. … February 12, 2020 The Critical Care Safety Study: the incidence and nature of adverse … June 29, 2009 Predictive power of the "trigger tool" for the detection of adverse events … the Medicare Sepsis Performance Measure (SEP-1). … October 21, 2020 Information concerning ICU patients’ families in the handover—the clinicians

2860. Patient safety skills in primary care: a national survey of GP educators. | PSNet
      psnet.ahrq.gov/issue/patient-safety-skills-primary-care-national-survey-gp-educators
      October 05, 2016 - View more articles from the same authors. … surveyed regarding how they perceived the importance of each of these skills. … implemented widely in the United Kingdom. … COVID-19 pandemic in the UK-Qualitative assessment. … April 14, 2021 Organizational readiness to change as a leverage point for improving safety