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Showing results for "the change teams".

3041. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837791/psn-pdf
      August 05, 2022 - the COVID? … The rapidly changing epidemiology of the virus, and the energy and resources that, by necessity, were … Fortunately, aspects of the emergency responses to the COVID? … care safety in the future.2,3 The more things change, the more the same core themes continue to stand … One way to foster change is for health delivery systems to leverage their infrastructure and facilitate

3042. Medication Reconciliation: Whose Job Is It? | PSNet
      psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
      May 01, 2018 - The nurse caring for the patient misinterpreted the EMAR and gave an excessive amount of the gabapentin … The patient told the nurse that the amount of medicine given seemed to be more than she was accustomed … Although the overdosage was noted at the time, the administration of the incorrect drug (Neurontin, instead … the preoperative consultant's error to propagate from the outpatient to the inpatient setting. … to the pharmacist, making it impossible for the pharmacist to compare the admission orders against the

3043. Patient Safety in the Ambulatory Care Setting | PSNet
      psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
      April 27, 2022 - The rapidly changing epidemiology of the virus, and the energy and resources that, by necessity, were … three decades of quality and safety work. 1 At the same time, the COVID‑19 crisis affords the opportunity … 2 , 3 The more things change, the more the same core themes continue to stand out for their importance … since the pandemic began. … One way to foster change is for health delivery systems to leverage their infrastructure and facilitate

3044. Creation of a Medical Procedure Service to Improve Patient Safety | PSNet
      psnet.ahrq.gov/perspective/creation-medical-procedure-service-improve-patient-safety
      March 01, 2008 - In our initial model, the intern caring for the patient was the primary operator of the procedure. … This also frees the busy ward teams to continue in other patient-related activities rather than rushing … This change allows residents who are interested in procedure-oriented fields or who are interested in … We've slowly added to our "menu" over the years based on the needs of the referring physicians and the … The nurse also helps to clean up afterward, helps collect the data, and helps to move the cart and the

3045. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33710/psn-pdf
      May 01, 2011 - RW: So did the shift in the patient safety field, emphasizing the role of systems, make it easier for … Does it change the nature of the second victim? … What is the role of the apology for the provider? … In a way they suffer at the expense of the rest of the organization's learning about systems of care … the harm to the second victim.

3046. Impact of System Failures on Healthcare Workers | PSNet
      psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
      August 30, 2023 - The news of Vaught’s conviction led healthcare professionals to reflect on the impact that the conviction … In the wake of the guilty verdict, many organizations released public statements against the criminalization … of medical errors based on the impact it could have on the disclosure of errors and near miss events … from the plan. … Because of this disagreement, we avoid the use of the term and refer to the traumatic effects that are

3047. Wrong Catheter in the Right Patient | PSNet
      psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
      May 16, 2022 - With the next shift change, a new team took over and after a few hours, the IR nurse called asking for … When the unit nurse came in to assess the patient, the physician walked in at the same time and both … of a PICC by the night nurse who had taken the verbal order from the physician.  … During the shift change that morning, the sign-out to the day shift nurse indicated that PICC insertion … If the telephone call occurred at the end of the shift, the nurse might have been fatigued, especially

3048. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33779/psn-pdf
      March 01, 2015 - enormous numbers of handoffs in health care delivery organizations (e.g., between nurses at shift change … of the hazards of handoffs. … the hospital setting. … Unfortunately, the results of the studies served mostly to reinforce the notion that there is https: … The review below focuses on some of the highest impact studies in this area.

3049. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.84_slideshow.ppt
      December 01, 2004 - Case #2 (cont.): Discharge Fumbles The patient presented to the ED the following day with mental status … It was determined that the pharmacy mistook the original order for Reminyl as Amaryl. … The incidence and severity of adverse events affecting patients after discharge from the hospital. … On the other hand if the diarrhea is picked up early and the patient responds to treatment, it will not … The importance of postdischarge telephone follow-up for hospitalists: a view from the trenches.

3050. In Conversation With… Enrico Coiera, MB, BS, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-enrico-coiera-mb-bs-phd
      February 01, 2014 - error, which means you forget to do the last element in the sequence—the cleanup bit. … This is the notion of the sterile cockpit, the "no interruption zone." … As we know one of the most important rules for activating medical emergency teams is concern by clinicians … to conform to the needs of the record. … , the people around you, and the task at hand.

3051. Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations | PSNet
      psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizations
      October 27, 2022 - The tables below show what the pharmacist and prescriber(s) saw, or would have seen, in the PDMP at key … For each controlled substance prescription, the PDMP shows the date filled, the drug name and formulation … Transitions of care initiatives and teams are taking on increasing responsibility to address these challenges … Care teams should ensure their patients have enough supply of medication if the plan is to have them … Care teams can use the tools and strategies outlined herein to minimize risks for patients who are on

3052. Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation | PSNet
      psnet.ahrq.gov/web-mm/agitated-delirium-contributes-missed-testing-and-delayed-diagnosis-gastric-perforation
      June 28, 2023 - the change of shift, which occurred right after NGT placement. … cause of the patient’s agitation, attributed it to delirium, or reported this acute change to any of … change-of-shift, led to more serious consequences from his iatrogenic injury. … the proximal end of the tube at the tip of the patient’s nose, looping the tube behind the patient’s … between the bedside and charge nurses, at nursing change of shift, and between the nurse and supervising

3053. High prevalence of medication discrepancies between home health referrals and Centers for Medicare and Medicaid Services home health certification and plan of care and their potential to affect safety of vulnerable elderly adults. | PSNet
      psnet.ahrq.gov/issue/high-prevalence-medication-discrepancies-between-home-health-referrals-and-centers-medicare
      December 23, 2011 - View more articles from the same authors. … Medication reconciliation at the time of hospital discharge is a key patient safety practice. … The authors conclude that more work is needed to enhance care coordination to ensure accurate medication … Ten persistent hazards and inefficiencies with the use of medication administration technology from the … October 23, 2024 Measurement and training of TeamSTEPPS dimensions using the Medical

3054. Clinician collaboration to improve clinical decision support: the Clickbusters initiative. | PSNet
      psnet.ahrq.gov/innovation/clinician-collaboration-improve-clinical-decision-support-clickbusters-initiative
      October 21, 2020 - Clinician collaboration to improve clinical decision support: the Clickbusters initiative. … Using the Plan-Do-Study-Act model, the Clickbuster initiative assesses the performance of CDS alerts … January 8, 2020 Recommendations for the safe, effective use of adaptive CDS in the US … past and (re)imagining the future. … December 14, 2022 The development and piloting of the Ambulatory Electronic Health Record

3055. Impact of an electronic alert notification system embedded in radiologists' workflow on closed-loop communication of critical results: a time series analysis. | PSNet
      psnet.ahrq.gov/issue/impact-electronic-alert-notification-system-embedded-radiologists-workflow-closed-loop
      November 26, 2014 - View more articles from the same authors. … and the treating physician for abnormal test results following implementation of an electronic alert … The system allows radiologists to send alerts within their workflow for synchronous communication via … The authors used an automated text searching algorithm to identify radiology reports with and without … March 30, 2022 An initiative to improve the management of clinically significant test

3056. Characteristics of initial prescription episodes and likelihood of long-term opioid use—United States, 2006–2015. | PSNet
      psnet.ahrq.gov/issue/characteristics-initial-prescription-episodes-and-likelihood-long-term-opioid-use-united
      April 24, 2018 - View more articles from the same authors. … The authors recommend prescribing fewer than 7 days of opioids for acute pain and adhering to the Centers … 7 XML Endnote tagged PubMedId RIS Download Citation Related Resources From the … engineering and human factors support of a system of novel EHR-integrated tools to prevent harm in the … December 19, 2016 The Food and Drug Administration's National Drug Code Directory.

3057. 'Matching Michigan': a 2-year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England. | PSNet
      psnet.ahrq.gov/issue/matching-michigan-2-year-stepped-interventional-programme-minimise-central-venous-catheter
      April 29, 2015 - View more articles from the same authors. … The authors note the need for ethnographic studies to complement traditional clinical research in order … to determine the reasons behind the success (or failure) of quality improvement efforts. … April 29, 2015 Findings of the first consensus conference on medical emergency teams. … Improving the implementation and adherence of the surgical safety checklist: a quality improvement project

3058. Why do we still page each other? Examining the frequency, types and senders of pages in academic medical services. | PSNet
      psnet.ahrq.gov/issue/why-do-we-still-page-each-other-examining-frequency-types-and-senders-pages-academic-medical
      September 11, 2019 - Examining the frequency, types and senders of pages in academic medical services. … View more articles from the same authors. … Despite the ubiquity of smartphones , the vast majority of physicians still rely on one-way pagers for … hospital and compared the data to a similar study performed in 1988. … This represented a nearly 50% increase in the volume of pages compared to 1988.

3059. Are teaching hospitals treated fairly in the Hospital-Acquired Condition Reduction Program? | PSNet
      psnet.ahrq.gov/issue/are-teaching-hospitals-treated-fairly-hospital-acquired-condition-reduction-program
      July 11, 2018 - Are Teaching Hospitals Treated Fairly in the Hospital-Acquired Condition Reduction Program? … View more articles from the same authors. … The Hospital-Acquired Condition Reduction Program (HACRP) was established by the Centers for Medicare … myth of the "safest" hospital. … patients admitted through the emergency department.

3060. A comparative study measuring the difference of healthcare workers reactions among those involved in a patent safety incident and healthcare professionals while working during COVID-19. | PSNet
      psnet.ahrq.gov/issue/comparative-study-measuring-difference-healthcare-workers-reactions-among-those-involved
      February 15, 2023 - View more articles from the same authors. … July 27, 2022 The Psychological Safety Scale of the Safety, Communication, Operational … September 28, 2022 The perception of the patient safety climate by health professionals … during the COVID-19 pandemic-international research. … December 2, 2020 Attending to the emotional well-being of the health care workforce in