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Showing results for "the change teams".

2981. Evaluation of symptom checkers for self diagnosis and triage: audit study. | PSNet
      psnet.ahrq.gov/issue/evaluation-symptom-checkers-self-diagnosis-and-triage-audit-study
      December 08, 2021 - View more articles from the same authors. … This study used standardized patient cases to examine the accuracy of 23 publicly available services … The online services listed the correct diagnosis first in about one-third of instances and listed the … correct diagnosis in the top 20 possible diagnoses in more than half of cases. … These data do not support the use of online symptom checkers for diagnosis or triage and argue for use

2982. Role of the regulator in enabling a just culture: a qualitative study in mental health and hospital care. | PSNet
      psnet.ahrq.gov/issue/role-regulator-enabling-just-culture-qualitative-study-mental-health-and-hospital-care
      October 06, 2021 - View more articles from the same authors. … Three themes emerged – (1) the role of the inspector as both a catalyst for learning and a potential … August 31, 2022 The doctor was rude, the toilets are dirty. … Utilizing 'soft signals' in the regulation of patient safety. … August 10, 2022 How U.S. teams advanced communication and resolution program adoption

2983. "It's like two worlds apart": an analysis of vulnerable patient handover practices at discharge from hospital. | PSNet
      psnet.ahrq.gov/issue/its-two-worlds-apart-analysis-vulnerable-patient-handover-practices-discharge-hospital
      January 15, 2025 - View more articles from the same authors. … used in-depth interviews with patients, hospital staff, and primary care providers to better define the … May 26, 2014 The influence of context on the effectiveness of hospital quality improvement … handover—the clinicians’ “game of whispers”: a qualitative study. … October 14, 2020 Shift change handovers and subsequent interruptions: potential impacts

2984. Does patient-centered design guarantee patient safety?: Using human factors engineering to find a balance between provider and patient needs. | PSNet
      psnet.ahrq.gov/issue/does-patient-centered-design-guarantee-patient-safety-using-human-factors-engineering-find
      November 23, 2016 - The investigators begin with a detailed discussion of the contextual factors involved in their hospital … Results from the 270 clinical faculty and staff surveys suggested that the majority reported a better … As perhaps expected, the findings demonstrated many benefits and some unanticipated consequences of the … June 1, 2022 Graduating pediatrics residents' reports on the impact of fatigue over the … January 20, 2016 Improving the quality of the surgical morbidity and mortality conference

2985. Intensive care unit critical incident analysis as an objective tool to select content for a simulation curriculum. | PSNet
      psnet.ahrq.gov/issue/intensive-care-unit-critical-incident-analysis-objective-tool-select-content-simulation
      June 28, 2023 - View more articles from the same authors. … In this retrospective study, researchers identified the occurrence of common ICU scenarios and skills … The analysis found that more than 25% of trainees reported low levels of confidence in three scenarios … – familiarity with the advanced life support trolley, electrocardiogram strip interpretation , and … unit during the COVID-19 pandemic: a multicentre qualitative study.

2986. Associations between double-checking and medication administration errors: a direct observational study of paediatric inpatients. | PSNet
      psnet.ahrq.gov/issue/associations-between-double-checking-and-medication-administration-errors-direct
      January 18, 2023 - View more articles from the same authors. … The researchers in this study directly observed nurses administering medications to pediatric patients … to measure the association between double-checking and medication administration errors . … These f inding s raise questions about the benefits compared to single-checking. … on pediatric resuscitation teams.

2987. Effects on resident work hours, sleep duration and work experience in a Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS). | PSNet
      psnet.ahrq.gov/issue/effects-resident-work-hours-sleep-duration-and-work-experience-randomized-order-safety-trial
      March 10, 2021 - View more articles from the same authors. … In this clustered-randomized trial across six academic medical centers, researchers examined the impact … September 28, 2010 The Critical Care Safety Study: the incidence and nature of adverse … April 11, 2011 The impact of duty hours on resident self reports of errors. … era of the 80-hour resident workweek.

2988. Nature and timing of incidents intercepted by the SURPASS checklist in surgical patients. | PSNet
      psnet.ahrq.gov/issue/nature-and-timing-incidents-intercepted-surpass-checklist-surgical-patients
      September 20, 2011 - View more articles from the same authors. … Checklists have been integral components in some of the most notable successes of the patient safety … However, the mechanism by which checklists improve outcomes is not entirely clear. … The majority of these were detected postoperatively—even though checklist adherence was lowest in the … systems in the Netherlands.

2989. What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation? | PSNet
      psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation
      September 01, 2006 - Can health care organizations really change? … Luckily, a change agent arrived in 1994 in the form of Ken Kizer. … to change than VA, aiming for the same goals. … The EHR system, CPRS, gave providers a powerful tool for change. … My goal when I came here was to change the culture.

2990. An Incomplete Anesthesia History Leads to Adverse Outcomes | PSNet
      psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
      January 29, 2021 - 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

2991. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong. | PSNet
      psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong
      March 03, 2021 - 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

2992. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-471
      December 31, 2024 - individual instead of the system. … Study Examining patient safety events using the behaviour change wheel: a cross-sectional … Using a behavioral change framework, the research team found poor alignment between the underlying causes … of the events and the type of intervention/follow-up action in one-third of the cases. … The commentary discusses the contraindications for beta-blockers in the setting of acute decompensated

2993. Volume Too Low: In and Out | PSNet
      psnet.ahrq.gov/web-mm/volume-too-low-and-out
      July 01, 2017 - The night nurse communicated the minimal intake of fluids and poor urine output to the day nurse at the … 7:00 AM change of shift. … The day nurse, busy caring for other patients, failed to appreciate the significance of the low intake … The fifth colleague puts 3,000 mg on the table. … scores or rapid response teams.

2994. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49552/psn-pdf
      January 01, 2008 - The resident then realized that the effusion was on the contralateral side, not the left side she had … One is the patient outcome resulting from the error, and the other is the degree of personal responsibility … The resident was devastated by the error. … One week after the patient passed away, the wife called the hospital where the event occurred and asked … Residents' responses to medical error: coping, learning, and change. Acad Med. 2006;81:86-93.

2995. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49828/psn-pdf
      May 01, 2018 - Her colleague was covering the electronic inbox (the portal within the electronic health record in which … the following week, the covering physician gave her the patient's last name but did not provide his … by The Joint Commission) (14), the returning rheumatologist would have looked up the medical record … result in the inbasket of the returning rheumatologist? … Third, this case highlights the potential role the patient could have played as part of the care team

2996. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49702/psn-pdf
      March 01, 2014 - The admitting team re-examined all of the information and realized the clinical presentation was not … on the admitting team wondered why the diagnosis had not been made during the previous admissions. … She felt like this was a diagnostic error—that the multiple clinicians and teams who had cared for the … What was the most effective way to give feedback to the previous teams? … In our opinion, the appropriate response of the individual clinician and the health care system should

2997. Failure to Rescue | PSNet
      psnet.ahrq.gov/primer/failure-rescue
      September 15, 2024 - Background and Theory The concept of failure-to-rescue (FTR) captures the idea that many complications … Throughout the 1990s, anesthesiologists led efforts to promote the capacity to detect and respond to … Medical emergency and rapid response teams (RRTs), including nurse-led teams with intensivist physician … (situation, background, assessment, recommendations), allied handover tools, and multidisciplinary teams … April 20, 2022 Rapid response teams as a patient safety practice for failure to rescue

2998. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60790/psn-pdf
      February 23, 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, … pandemic may require dentists to change their workflows62,63 or re-configure their clinic layouts besides … ADA asks CDC to change dental guidance on COVID-19. DentistryIQ. May 6, 2020. … statement-on-dentistry-as-essential-health-care https://www.dentistryiq.com/dentistry/article/14175481/ada-asks-cdc-to-change-dental-guidance-on-covid19

2999. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33596/psn-pdf
      June 01, 2025 - Background and Theory The concept of failure-to-rescue (FTR) captures the idea that many complications … Throughout the 1990s, anesthesiologists led efforts to promote the capacity to detect and respond to … From an HRO perspective, the capacity for organizational resilience is based on understanding that the … Medical emergency and rapid response teams (RRTs), including nurse-led teams with intensivist physician … (situation, background, assessment, recommendations), allied handover tools, and multidisciplinary teams

3000. Right Regimen, Wrong Cancer: Patient Catches Medical Error | PSNet
      psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
      August 01, 2006 - Describe the importance of understanding the process of chemotherapy administration and the importance … require chemotherapy.( 15 ) Dedicated oncology units staffed by medical oncologists have been replaced by teams … The initial error—pulling the wrong paper order set—went undetected by the outpatient oncologist, the … The discovery of the error by the patient is notable and the team is to be commended for responding rapidly … February 1, 2013 Perspective Organizational Change