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Showing results for "the change teams".

3001. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865376/psn-pdf
      March 27, 2024 - In the OR, blood was found in the peritoneal space. … treatment, she remained hemodynamically unstable with declining neurological function; her family opted to change … the diaphragm, and at the caudal edge of the liver. … The left upper quadrant is examined between the spleen and the diaphragm and the left pericolic gutter … Such efforts empower trauma teams to understand their previous failures, learn from previous successes

3002. Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions. | PSNet
      psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions
      March 19, 2019 - The patient informed the pharmacy of the error, for which the pharmacist acknowledged the mistake, apologized … The eight rights are: the right patient, the right drug, the right time, the right dose, the right route … , the right documentation, for the right reason, and the right response. … intqhc/mzm018 Improving Medication Safety in Community Pharmacy: Assessing Risk and Opportunities for Change … Author(s) Measuring the teamwork performance of teams in crisis situations: a systematic

3003. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33637/psn-pdf
      August 01, 2006 - I was always interested in how to change things and make the world a better place, but I guess everybody … We're talking about a major culture change. It's going to take years. … Was that a conscious change in focus on your part? LL: Yes. … It seemed to me that I have less to contribute to the ongoing efforts toward system change. … I expect that to grow and to help change the culture more than anything.Finally, I've been very encouraged

3004. Errors in Sepsis Management | PSNet
      psnet.ahrq.gov/web-mm/errors-sepsis-management
      November 03, 2015 - timing of the antibiotic administration was appropriate (the patient was in the ED for which the guideline … In order to maximize timely adherence to the bundle, institutions have created sepsis teams. … facilitate the ordering of the bundle elements. … When the patient's chart is subsequently entered by a nurse or other provider, the alert stating the … Identify Sepsis-Related Organ Dysfunction Hypotension with SBP 40 mm Hg from baseline Acute change

3005. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? | PSNet
      psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
      March 01, 2004 - in the operating room at the time of wound closure. … The death was unexpected, particularly given the patient's low preoperative risk, and the family and … the public and the media is low. … Conduciveness to change The detection method should capture sufficient detail to understand the … June 22, 2022 Expanding the scope of Critical Care Rapid Response Teams: a feasible approach

3006. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60241/psn-pdf
      February 24, 2022 - Due to the highly contagious nature of COVID-19 and the number of deaths in NHs, the Senate asked the … strike teams comprised of clinicians and public health officers from CMS, CDC, and the Office of the … teams were to focus on four key areas of support: preventing COVID-19 from entering the NHs, rapidly … Many states also created strike teams and offered intense training for NHs. … For example, California sent state strike teams out to conduct training on infection control and continued

3007. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836876/psn-pdf
      May 16, 2022 - The unpredictability of the scene, environmental issues like lighting (or lack thereof), and the need … include that they are reactive, difficult to use for trending and benchmarking, and not conducive to change … on individual error to a Just Culture where the system is the primary focus. … among staff, to getting a baseline assessment of culture, to examining trends over time, to measuring change … and staff have the seeds to grow the culture of safety in EMS organizations.

3008. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33569/psn-pdf
      June 15, 2024 - Background Being discharged from the hospital can be dangerous. … Finally, the fragmented nature of the health care system may limit individual hospitals' incentive to … These studies, the Care Transitions trial and the Project RED study, both successfully reduced readmissions … There is considerable interest in harnessing the power of checklists to standardize the discharge process … Evaluating the effectiveness of care transitions interventions is hindered by the fact that the standard

3009. The Role of Community Pharmacists in Patient Safety | PSNet
      psnet.ahrq.gov/perspective/role-community-pharmacists-patient-safety
      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.

3010. CVC Removal: A Procedure Like Any Other | PSNet
      psnet.ahrq.gov/web-mm/cvc-removal-procedure-any-other
      October 01, 2018 - 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 training … 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.

3011. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49470/psn-pdf
      December 01, 2004 - The patient presented to the ED the following day with mental status changes. … It was determined that the pharmacy mistook the original order for Reminyl as Amaryl. … In addition to the number of medications, the type of drug is also important. … actually receive the document.(5) This often happens because the hospital sends the letter to the family … On the other hand, if the diarrhea is picked up early and the patient responds to treatment, it will

3012. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60044/psn-pdf
      March 16, 2020 - Over the past two decades, the competency-based evolution in education has shifted the focus to outcomes … released the Quality Improvement and Patient Safety Competencies Across the Learning Continuum report … A careful review of the existing overall curricula for ways the competencies are already being taught … With the rise of remote learning and the growth in capabilities for online courses and instruction, … of patient safety concepts into curricula and the clinical learning environment, while at the same

3013. Sick and Pregnant | PSNet
      psnet.ahrq.gov/web-mm/sick-and-pregnant
      August 25, 2021 - The ED physician contacted the on-call internist to admit the patient for continued therapy. … The internist agreed to admit the patient, but he was not told that the patient was pregnant. … The admitting nurse received a report from the ED nurse, but again, the patient's pregnancy status was … In the morning, the internist saw the patient. She informed him that she was pregnant. … Third, the nurse administering the medication could have verified the patient's pregnancy by asking the

3014. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853981/psn-pdf
      September 27, 2023 - The next day, the patient remained in the ED awaiting an inpatient medical bed. … at the time of the hanging (leading to more impulsive behavior at the time of the hanging), the patient … Indeed, inpatient psychiatry consultation-liaison teams routinely see patients admitted to the intensive … Mobile mental health crisis response teams have recently been designed to collaborate with police officers … Depending on local service structures, mobile crisis teams may have clinicians with master’s degrees

3015. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.263_slideshow.ppt
      March 01, 2012 - The nurse learned about the worsening symptoms and contacted the discharging team. … Concerned that the patient’s pneumonia was returning and she was failing the doxycycline treatment, the … The patient’s daughter was able to get the prescription the same day and the patient began taking the … With the change in antibiotics, the patient felt much better. … The discharging team was convinced that the follow-up phone call from the nurse had definitely prevented

3016. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49424/psn-pdf
      November 01, 2003 - The anesthesiologists were short-staffed and also covering the operating rooms on a different floor, … The Commentary What went wrong? … second half of the 1990s, the number of residents graduating from anesthesiology training programs … ’s exact whereabouts, it is generally understood to imply the anesthesiologist must be in the hospital … In this case, what was told to the anesthesiologist by the obstetrician?

3017. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.164_slideshow.ppt
      December 01, 2007 - Case: Elopement On the morning of anticipated discharge, the patient was not in his room at the time … of the physician visit. … simultaneously to both the inpatient floor and the ED. … Case (cont.): Elopement Even though the ED staff had noted the patient to be mildly confused, in the … simultaneously to both the inpatient floor and the ED.

3018. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.353_slideshow.ppt
      August 01, 2015 - In this case, the patient requiring the brain MRI had the same initials as another patient on the same … The cross-covering resident mixed up the two patients and placed the MRI order in the wrong chart. 5 … The following morning, the primary team caught the error and the MRI was canceled and ordered for the … The Importance and Value of Protecting the Privacy of Health Information: The Roles of the HIPAA Privacy … Paving the regulatory road to the "learning health care system."

3019. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49830/psn-pdf
      May 01, 2018 - Suicide Risk in the Hospital May 1, 2018 Mills PD. Suicide Risk in the Hospital. … On arriving to the unit, the patient asked to use the bathroom. … Mills, PhD, MS Suicide is the 10th leading cause of death in the United States, resulting in the deaths … The next breakdown in the case was allowing the patient to be on her own without a clinical evaluation … change the members on the review team in order to have fresh input on what constitutes a hazard.

3020. Healthcare-associated Infections | PSNet
      psnet.ahrq.gov/primer/health-care-associated-infections
      December 15, 2024 - infections increased from 2019 to 2020, the first year of the pandemic. … The CDC has evidence-based  guidelines  that detail methods to prevent specific HAIs in the inpatient … The combination of improvement in organizational culture and use of the checklist has powered the reductions … The effect of these policies, as well as the CMS nonpayment policy for HAIs, remains unclear. … The most recent  data  from the  Partnership for Patients  Initiative indicates that the overall rate