Results

Total Results: 3,566 records

Showing results for "the change teams".

3021. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33881/psn-pdf
      August 01, 2019 - It feels pretty different than the plight of the pilot behind the locked door or the nuclear power plant … RW: When I sit on the Patient Safety Committee and we hear about cases, it strikes me that to change … anything now almost always involves a change in the way the electronic health record either works or … the system and possibly change or make improvements so it would be easier for them to do their work. … But the point is that the return-on-investment is not immediate. The return is in the longer term.

3022. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33624/psn-pdf
      December 01, 2005 - prevention would it be possible to effect any change. … constituencies who really don't want change. … There's obviously no interest in change on the part of the plaintiff's attorneys because, their role … not radical change that might jeopardize their particular line of business. … A change in system really makes it more difficult for them.

3023. In Conversation With… John Halamka, MD, MS | PSNet
      psnet.ahrq.gov/perspective/conversation-john-halamka-md-ms
      March 27, 2024 - 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

3024. Finding Fault With the Default Alert | PSNet
      psnet.ahrq.gov/web-mm/finding-fault-default-alert
      August 28, 2024 - In review of the resident's discharge note, the discharge plan for the phenytoin was clearly stated, … 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 … An analysis of incident reports related to electronic medication management: how they change … Medication errors related to computerized provider order entry systems in hospitals and how they change

3025. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49666/psn-pdf
      October 01, 2012 - down the mats. … The pediatrician incised the lesion, expressed pus, and cultured the fluid. … Deep tissue debridement of the hip lesion was performed in the intensive care unit (ICU) because the … All individuals associated with competitive sports teams, including players, coaches, teachers, parents … Take-Home Points To prevent sports-related skin infections, everyone involved in sports teams should

3026. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.338_slideshow.ppt
      January 01, 2015 - The infant required extensive resuscitation but survived and was transferred to the neonatal intensive … Two nurses at the nursing station were assigned to watch the monitor at the time of the concerning abnormalities … When asked about the incident, the nurses both replied that they "just didn't see the bad tracings" and … physiology of fetal monitoring Open and clear communication between health care teams Common buy-in … abnormal FHR tracings are encountered requires: Open and transparent communication between health care teams

3027. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33705/psn-pdf
      January 01, 2011 - was not until 1999, when the Institute of Medicine highlighted the New York state data (including the … Many organizations, including the National Patient Safety Foundation, the Leapfrog Group, and the Institute … The reviews from experts speak to whether or not the provider met the standard of care and, more important … Further, the information available is deep—providing a close look at the experience of both the patients … The Report of the Harvard Medical Practice Study to the State of New York.

3028. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49683/psn-pdf
      April 01, 2013 - The ED work-up was consistent with acute pancreatitis and the patient was admitted to the hospital. … In addition, the GI consult described how the patient requested a reduction in the haloperidol dose … The GI consult declined the patient's request and suggested that changes in the haloperidol dose, as … The Commentary The case highlights the life-threatening potential of major mental illness, the complexities … The failure to recognize the importance of changing the psychiatric medication by the non- psychiatric

3029. Moved Too Soon | PSNet
      psnet.ahrq.gov/web-mm/moved-too-soon
      November 01, 2006 - 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 … patient location change to be made in an already occupied bed.

3030. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73998/psn-pdf
      October 27, 2021 - During the surgical procedure, the neurosurgeon adjusted the patient’s head, displacing the external … include the ability to aspirate blood from the catheter with a syringe, the ability to easily inject … size of catheter required, the expected stability of the catheter in the proposed insertion site, and … During the second communication phase, the surgeon is asked to confirm the anticipated blood loss and … //doi.org/10.1097/aco.0000000000000112 https://doi.org/10.4103/2229-5151.100890 https://www.who.int/teams

3031. Waiting Too Long | PSNet
      psnet.ahrq.gov/web-mm/waiting-too-long
      February 01, 2013 - The Case A 31-year-old gravida 1, para 1 woman presented at 40 weeks in the early stages of labor having … The anesthesiologists were short-staffed and also covering the operating rooms on a different floor, … The Commentary What went wrong? … In this case, what was told to the anesthesiologist by the obstetrician? … In the setting of no serious vaginal bleeding and the absence of a worrisome ("non-reassuring") fetal

3032. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/864867/psn-pdf
      April 10, 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. … Isolated sensory symptoms without weakness (S) The higher the score, the more likely a “stroke mimic … Although the medical history and the physical examination are the bedrock of clinical reasoning, patients

3033. In Conversation with…David W. Bates, MD, MSc | PSNet
      psnet.ahrq.gov/perspective/conversation-withdavid-w-bates-md-msc
      May 01, 2018 - He is the Board Chair of the American Medical Informatics Association (AMIA), a member of the Institute … On the outpatient front, the big issue is that 89% of the return after a provider starts using electronic … records goes to the purchasers and the payers. … DB: Well, I think that the market is ripe for change and that we could see a large company like a Microsoft … avoid using proprietary data structures, and that has required a lot of health care IT companies to change

3034. Integrating Multiple Medication Decision Support Systems: How Will We Make It All Work? | PSNet
      psnet.ahrq.gov/perspective/integrating-multiple-medication-decision-support-systems-how-will-we-make-it-all-work
      May 01, 2008 - Simulate the impact of the CDSS using retrospective data. … He is the Board Chair of the American Medical Informatics Association (AMIA), a member of the Institute … records goes to the purchasers and the payers. … DB: Well, I think that the market is ripe for change and that we could see a large company like a Microsoft … avoid using proprietary data structures, and that has required a lot of health care IT companies to change

3035. Hindsight is 20/20: Thrombolytics for Alcohol Intoxication | PSNet
      psnet.ahrq.gov/web-mm/hindsight-2020-thrombolytics-alcohol-intoxication
      December 18, 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. … higher the score, the more likely a “stroke mimic.” … Although the medical history and the physical examination are the bedrock of clinical reasoning, patients

3036. The Wet Read | PSNet
      psnet.ahrq.gov/web-mm/wet-read
      October 01, 2017 - The on-call radiology resident read the study, contacted the ordering physician, and reported that his … 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.

3037. Medication Reconciliation With a Twist (or Dare We Say, a Patch?) | PSNet
      psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch
      April 03, 2024 - Although the family stated that the patient was on a "memory medicine," the reconciliation list did not … Based on this discrepancy, the consulting service contacted the outpatient pharmacy and learned the patient … She had not been prescribed the drug during the hospital stay, and the last patch had been placed more … abrupt withdrawal of the cholinesterase inhibitor contributed to the episode. … The BPMH was eventually determined by the geriatrics consulting team in collaboration with the outpatient

3038. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866826/psn-pdf
      September 25, 2024 - on the back of the machine. … of the gas in the cylinder before they administer the gas to the patient via a non-rebreather mask. … At the end of the procedure nitrous oxide diffuses from the blood into the alveoli at a faster rate … .11 The gas flow through the cross-connection depends on the difference in pressure between the two … Have a low threshold to change to a different gas supply Whenever desaturation occurs very rapidly,

3039. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49760/psn-pdf
      May 01, 2016 - https://psnet.ahrq.gov/web-mm/mismanagement-delirium committed, and no change in placement or treatment … The family then called the patient's primary care physician, who deferred to the specialists on the … The ward nurse refused the request and the wife and daughter were escorted from the locked ward at 9 … Hallmark signs include an abrupt change in cognition, variability in level of consciousness, and disrupted … Take-Home Points An acute change in cognition and behavior in a patient with dementia requires immediate

3040. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/848124/psn-pdf
      April 26, 2023 - ideas, perform analysis, and think about all of the components from the micro to the macro level of … pop the air bag to save the occupant. … They’re close to the bedside all the time, and they can respond and adjust the monitoring system so … The engineer mapped the existing workflow of nurses at the bedside and thought about how the monitor … line as the system processes the sensor data.