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Showing results for "the change teams".

3061. "SWARMing" to improve patient care: a novel approach to root cause analysis. | PSNet
      psnet.ahrq.gov/issue/swarming-improve-patient-care-novel-approach-root-cause-analysis
      September 23, 2020 - based on the concept of swarm intelligence. … The authors describe the key structure and steps of their SWARM program, including the focus on actions … At the same time, the observed-to-expected mortality ratio decreased 37% from 1.2 to 0.7 across the health … May 13, 2015 Evaluation of the suitability of root cause analysis frameworks for the … Learning from preventable deaths: exploring case record reviewers' narratives using change

3062. Usability of a computerised drug monitoring programme to detect adverse drug events and non-compliance in outpatient ambulatory care. | PSNet
      psnet.ahrq.gov/issue/usability-computerised-drug-monitoring-programme-detect-adverse-drug-events-and-non
      December 21, 2014 - View more articles from the same authors. … The authors identified several limitations: the system only reached 70% of patients despite multiple … April 29, 2018 The Canadian Adverse Events Study: the incidence of adverse events among … the phases of medication management: a systematic review of randomized controlled trials. … April 22, 2011 Using Medical Emergency Teams to detect preventable adverse events.

3063. A national implementation project to prevent catheter-associated urinary tract infection in nursing home residents. | PSNet
      psnet.ahrq.gov/issue/national-implementation-project-prevent-catheter-associated-urinary-tract-infection-nursing
      April 05, 2017 - View more articles from the same authors. … The project was conducted over a 2-year period across 48 states. … this effort led to a significant decrease in catheter-associated urinary tract infections, despite no change … April 5, 2017 Evaluation of the association between Hospital Survey on Patient Safety … ICU: the Spanish experience.

3064. Families as partners in hospital error and adverse event surveillance. | PSNet
      psnet.ahrq.gov/issue/families-partners-hospital-error-and-adverse-event-surveillance
      December 19, 2018 - View more articles from the same authors. … About half the incidents reported by family members were determined to be safety concerns; fewer than … July 2, 2019 The hidden cost of regulation: the administrative cost of reporting serious … June 14, 2017 An improvement approach to integrate teaching teams in the reporting of … March 1, 2017 Electronic approaches to making sense of the text in the adverse event

3065. Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study. | PSNet
      psnet.ahrq.gov/issue/preventable-deaths-due-problems-care-english-acute-hospitals-retrospective-case-record-review
      July 20, 2022 - View more articles from the same authors. … The famous estimate that 44,000 to 98,000 patients die every year in the United States due to preventable … The investigators reviewed 1000 randomly selected deaths from 10 hospitals, using a standardized protocol … The majority of preventable deaths occurred in patients whose life expectancy was considered to be less … Learning from preventable deaths: exploring case record reviewers' narratives using change

3066. Burnout and its relationship to self-reported quality of patient care and adverse events during COVID-19: a cross-sectional online survey among nurses. | PSNet
      psnet.ahrq.gov/issue/burnout-and-its-relationship-self-reported-quality-patient-care-and-adverse-events-during
      August 25, 2021 - View more articles from the same authors. … August 25, 2021 Delayed access to care and late presentations in children during the … COVID-19 pandemic: a snapshot survey of 4075 paediatricians in the UK and Ireland. … October 20, 2021 The relationship between patient safety culture and the intentions of … the nursing staff to report a near-miss event during the COVID-19 crisis.

3067. Implicit bias and patient care: mitigating bias, preventing harm. | PSNet
      psnet.ahrq.gov/innovation/implicit-bias-and-patient-care-mitigating-bias-preventing-harm
      September 22, 2021 - View more articles from the same authors. … As part of the simulation, an orthopedic resident on the care team was pushing for involving child welfare … The simulation objectives were for the learners to (1) identify that the case was not concerning for … the resident and family to diffuse the situation and prevent any potential harm. … After the simulation, the simulation instructions led a debrief to discuss and reflect on the case.

3068. Weekend effect on in-hospital mortality for ischemic and hemorrhagic stroke in US rural and urban hospitals. | PSNet
      psnet.ahrq.gov/issue/weekend-effect-hospital-mortality-ischemic-and-hemorrhagic-stroke-us-rural-and-urban
      January 19, 2022 - View more articles from the same authors. … The ” weekend effect ” refers to worse patient outcomes occurring outside of usual business hours. … The authors used national data to examine in-hospital mortality differences among patients experiencing … stroke admitted on the weekend versus on a weekday. … Future research should explore the influence of additional factors, such as patient-level behavioral

3069. Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes | PSNet
      psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-safety-older-adults
      April 10, 2024 - 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

3070. The Hidden Danger of Unseen Intravenous Catheters | PSNet
      psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters
      October 04, 2023 - 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 … blood loss as well as the intravenous catheters obtained, the stability of the intravenous catheters

3071. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33805/psn-pdf
      April 01, 2016 - The CLER program is designed to nurture and bring together the clinical leadership at the level of the … called CLER Conversations, where we actually bring teams of medical staff, nursing staff, and educational … But as the teams have gone around on the floors and engaged nursing and respiratory therapy and the … For example, we don't see active engagement in root cause analysis by multidisciplinary teams. … [Editor's note: Since the time of the interview, the ACGME has announced the Pursuing Excellence in

3072. The Unhappy Patient Leaves Against Medical Advice. | PSNet
      psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice
      January 31, 2024 - By the time the nurse came to the bedside to change the patient’s urine-soaked bed pads and sheets, the … The nursing staff was unable to de-escalate the contentious situation and the patient insisted on “leaving … The charge nurse was unaware of these events until the on-call physician contacted the unit for more … The Commentary By Amy Nichols, EdD, RN, CNS, CHSE, ANEF The phenomenon of leaving the care setting … Had this process happened in the current case, the patient may have considered staying in the hospital

3073. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.215_slideshow.ppt
      April 01, 2010 - The patient delivered the prescription to the clinic pharmacy and it was filled. … The patient brought the medication to his physician, stating that the Rythmol tablets looked different … altered appearance of the tablets, both the patient and the physician suspected that this might not … When the physician spoke with the pharmacist who filled the prescription, it became apparent that a medication … Patient empowerment might have prompted patient to question pharmacist or physician about prescription change

3074. Adverse Events, Near Misses, and Errors | PSNet
      psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
      March 30, 2022 - These adverse events were the focus of both the Medical Insurance Feasibility Study and the Harvard Medical … The patient had continued rectal bleeding but was reassured by the physician. … the room. … so that the medications can be given to the correct patient. … As the science of patient safety advances, these judgments can change over time, such that more adverse

3075. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33570/psn-pdf
      June 15, 2024 - An extensive body of research has examined the causes of diagnostic error at the individual clinician … The autopsy has been the "gold standard" for diagnosis since medicine became a profession, but autopsy … rates have progressively declined over the past few decades, to the point where a recent editorial … Current Context The National Academy of Medicine (formerly the Institute of Medicine) released a report … interdisciplinary health care teams, enhancing patient engagement in the diagnostic process, implementing

3076. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33800/psn-pdf
      January 01, 2015 - The research on CPOE makes clear that the technology reduces prescribing errors. … oncology study demonstrated fewer chemotherapy medication errors using CPOE, while another found no change … Finally, evidence from a multicenter outpatient study did not find a change in the rate of preventable … the extent to which the CPOE system generated warnings or prevented the orders. … In 2015, the FDA released a white paper on the safety of CPOE systems.

3077. In Conversation with Lucy Savitz about Learning Health Systems for Patient Safety | PSNet
      psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learning-health-systems-patient-safety
      February 26, 2025 - Earlier in healthcare delivery, people talked about change management and referenced the work of Peter … They never really talked to the implementation teams that were doing the improvement work. … If there is a change in a CEO, for example, the priorities will shift and change. … with the priorities of the system. … As a result of this analysis, the learning health system made an evidence-based change to limit hip X-rays

3078. Learning Health Systems for Patient Safety | PSNet
      psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
      February 26, 2025 - As a result of this analysis, the learning health system made an evidence-based change to limit hip X-rays … Earlier in healthcare delivery, people talked about change management and referenced the work of Peter … They never really talked to the implementation teams that were doing the improvement work. … If there is a change in a CEO, for example, the priorities will shift and change. … with the priorities of the system.

3079. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33831/psn-pdf
      April 01, 2017 - learning led us to propose three major domains of change for how health care could get to high reliability … That's with Robust Process Improvement (RPI), Lean Six Sigma, Change Management. … Sigma, and Change Management. … technical solutions, sets of tools, and a systematic approach to change management around them, so … That pace of change has to pick up. It's disappointing that it hasn't spread more rapidly.

3080. Diagnosing a Missed Diagnosis | PSNet
      psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis
      October 26, 2022 - The bedside nurse told the physician that the patient seemed to be going to the bathroom frequently; … The physician attributed the rising sodium to the IV fluids and decided to continue aggressive hydration … diabetes insipidus (NDI), chronic tubulo-intersitial nephropathy, and nephrotic syndrome from minimal change … of the kidneys to appropriately concentrate the urine in the presence of antidiuretic hormone. … November 16, 2022 Perspective Organizational Change in