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Showing results for "the change teams".

3161. Diagnostic Errors in Medicine: What Do Doctors and Umpires Have in Common? | PSNet
      psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
      February 01, 2007 - The Table explores some of the similarities and differences between the fields as they pertain to " … Unlike umpires, we can (and often should) change our minds. … The umpire integrates his perception of the ball's path in the context of his knowledge of the strike … Ultimately, the biggest change that will push this paradigm even further is electronic medical records … physicians come up with the right differential diagnosis, we can bring about change much more easily.

3162. Miscalculated Risk | PSNet
      psnet.ahrq.gov/web-mm/miscalculated-risk
      March 01, 2015 - opiates, as well as a failure on the part of the pharmacist and nurse to appreciate the excessive dose … Third, divide the total 24-hour dose of the new drug by the number of daily doses to be administered. … The duration of action values in the Table are helpful in this regard. … Fourth, consider reducing the calculated dose of the new drug by 25%-50%. … Multiplying 54 mg by the dose ratio from the conversion table (20/10, or 2), the total expected 24-hour

3163. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33717/psn-pdf
      September 01, 2011 - when incident reporting has led to improvements in safety, making the best possible use of the information … that is reported, involving physicians in reporting, and leveraging the unique advantages of the 84 … The problem is that, in a landmark study of adverse events in hospitals, 94% of the events involved … penultimate phase of the incident reporting process entails reviewing the narrative, conducting an … Therefore, the safety feedback loop is vital to the effectiveness of incident reporting.

3164. Danger in Disruption | PSNet
      psnet.ahrq.gov/web-mm/danger-disruption
      July 29, 2020 - The anesthesiologist threw the needle on the floor and walked toward the door. … By mastering communication and confrontation skills, these individuals have begun to change the culture … approach to nurse–physician relationships has begun to change, partly because of two factors in health … exchange of facts and feelings can occur, there is a real possibility that physician behavior will change … Working together, nurses, physicians, and administrators can admit that change is needed and openly identify

3165. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33656/psn-pdf
      September 01, 2007 - It's still the bottom line that "The secret in caring for the patient is caring for the patient," as … recognize that we are not as good as we would like to be, our inherent professionalism will motivate us to change … AG: I told the story in the book about the 117 cystic fibrosis centers across the country, which work … between the median centers and the top centers. … We have now seen several examples of effective things you can do that really change complication rates

3166. The Forgotten Turn | PSNet
      psnet.ahrq.gov/web-mm/forgotten-turn
      August 01, 2018 - inpatient room during the change in nursing shifts at 7:00 AM. … Because of a mechanical problem with one of the beds, the patient was kept in the same bed she had been … The day nurse found the patient to be confused but oriented, pleasant, and clinically stable; the patient … The appropriate documentation is no longer just the domain of the nursing assessment. … of the chart, along with signs at the bedside.

3167. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74121/psn-pdf
      November 30, 2021 - Oxygen via face mask and position change were initiated, but the FHR remained depressed for 120 seconds … Through the first 90 minutes in the PACU, the uterine fundus remained moderately firm. … After 180 minutes in the PACU, the patient’s nurse discovered her unresponsive and the bedsheets were … The intervention plans start on the left of the chart with “Mobilize”, then “Act” and on the right with … There are three types of alarms generated by monitoring devices: arrhythmia alarms (change in cardiac

3168. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49667/psn-pdf
      October 01, 2012 - The patient died several minutes after the infusion. The error was noted during the code blue. … the medication and the dose. … moving around the unit amassing the vials needed for the dose. … While the nurse was undoubtedly trying to be helpful, the instinct of all clinicians has to change from … Clinicians should listen to each other's concerns, model good behavior, and facilitate change by learning

3169. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867805/psn-pdf
      February 26, 2025 - The other big change is that we are now using triggers to find adverse events, which were not https: … You mention the trigger tool as a methodological change for identifying those adverse events. … People then developed change packages which enabled other organizations to adopt the same practices. … Robust change packages are critical. … change that I think would make a difference. 

3170. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33843/psn-pdf
      October 01, 2017 - RW: I was wondering whether you'd say that there is a generational change? … The problem, however, is that the culture of the institutions is not changing. … What has been the experience? JS: The experience has been very mixed. … The study published in JAMA Pediatrics in 2015 showed that was one of the major concerns of the physicians … Institutions have to change their policies and look differently at how they measure productivity.

3171. In Conversation With… Christopher P. Landrigan, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-christopher-p-landrigan-md-mph
      April 01, 2013 - The first real policy change in 2003 limited the hours substantially in only a couple of specialties. … hours were not infrequently over 100 hours a week, an 80-hour workweek was a relatively substantive change … medicine, and family practice, it represented more of a minor rearrangement in hours than a revolutionary change … , because there simply wasn't much change in work hours or sleep. … RW : You led a now famous study that demonstrated no change in at least one way of measuring patient

3172. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/857260/psn-pdf
      November 30, 2023 - He was discharged the following day. … He was told only to hold it on the day of the procedure, and to resume all medications after discharge … The procedure was apparently successful, and the patient was discharged the next day with instructions … The human body can maintain normoglycemia through the breakdown of glycogen stores by the liver, which … The half-life of SGLT2i ranges from 11 to 17 hours, so even after holding the medication, the pharmacological

3173. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49820/psn-pdf
      February 01, 2018 - Given the extent of his injuries and the need for ongoing physical therapy, the plan was made to admit … , so the trauma team communicated these recommendations to the patient's PCP and the SNF in their discharge … The PCP had not received any communication from the SNF about the patient's discharge. … The patient did not need to be readmitted to the hospital and was able to stay at home, but the PCP … references https://psnet.ahrq.gov//#references https://psnet.ahrq.gov//#references Interdisciplinary teams

3174. When "Psychiatric" Symptoms Are Not | PSNet
      psnet.ahrq.gov/web-mm/when-psychiatric-symptoms-are-not
      September 20, 2011 - A friend of the patient’s reported the patient had believed for the past 5 to 7 years that the “shockers … In the 2 weeks prior to hospitalization, the patient reported they had somehow “upped the current.” … The consensus was that the patient’s prognosis was not affected by the several-day delay. … #1: The mistake of neglecting the medical risks associated with older age. … The emergence of medical symptoms (or change in psychiatric symptoms) in a 70-year-old should prompt

3175. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837748/psn-pdf
      August 05, 2022 - The patient was seen in the preoperative assessment clinic prior to admission, where the nursing staff … from the patient’s home medication list in the EHR. … However, when the nurse in the post-anesthesia care unit (PACU) double-checked the dose with the patient … Interventions at the Level of the Provider Obtain an Accurate Medication List In the first case, the … the EHR.

3176. Challenges of Diabetes Management and Medication Reconciliation | PSNet
      psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
      March 15, 2023 - The patient was seen in the preoperative assessment clinic prior to admission, where the nursing staff … from the patient’s home medication list in the EHR. … However, when the nurse in the post-anesthesia care unit (PACU) double-checked the dose with the patient … discharge from the hospital. 3 The IHI defines medication reconciliation as the formal process of … the EHR.

3177. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50841/psn-pdf
      January 29, 2020 - The patient was seen by the surgical and anesthesia teams in the preoperative holding area the morning … The goal of the blood delivery pathway is to deliver the right product to the right patient. … label is affixed to the container before the person who obtained the sample leaves the bedside. 5.12 … The downstream effect of the two errors was the wrong blood reaching the patient’s bedside, a high risk … underlying reason for the error is systemic and especially if a process change is made to ensure compliance

3178. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures | PSNet
      psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
      November 27, 2019 - treatment, she remained hemodynamically unstable with declining neurological function; her family opted to change … The tube is directed with the clamp and secured. … The right upper quadrant is examined for free fluid in the hepatorenal pouch, between the liver and the … 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

3179. Another Fall | PSNet
      psnet.ahrq.gov/web-mm/another-fall
      June 01, 2010 - The patient showed continued improvement and was transferred from the ICU to the step-down unit. … The next evening the patient attempted to climb out of bed by squeezing between the bed rails ( Figure … These transition points may lie between or among hospital teams or units, as in this case (including … such transitions as moving from the emergency department to the floor, or from the floor to the diagnostic … efficacy of hip protectors in preventing hip fractures,( 5 ) but this represents a change in emphasis

3180. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49537/psn-pdf
      June 01, 2007 - Preoperatively, the patient was evaluated by both the anesthesiology and surgery teams. … Given the prior AAA repair, the patient underwent surgery in the supine position. … The decision to undergo major surgery requires a careful assessment of the risks and benefits of the … So we fall back to the history: did the patient mention the mass or abdominal pain? … no change in the clinical status of the patient.(14) The primary care physician is responsible for