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Showing results for "the change teams".

3181. Microsoft PowerPoint - Spotlight Case_Postop Cervical Hematomas_12.15.2022 FINAL.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-01/spotlight_respiratory_distress_after_neck_surgery_two_cases_of_postoperative_cervical_hematoma.pdf
      January 01, 2023 - a 2.5 cm vertical laceration of the posterior pharynx below the uvula, with bleeding. … • The patient was discharged to a hotel across the street from the hospital, where a one-night stay … • 7 Case #2 Details (4) • The following morning, the patient called the surgery clinic to report … Surgical and anesthesia teams should work together, as hematoma evacuation may be required prior to … effort to evacuate the hematoma and secure the airway in the controlled environment of the operating

3182. A Painful Dilemma | PSNet
      psnet.ahrq.gov/web-mm/painful-dilemma
      September 01, 2013 - The unused clotted AV graft in the left arm remained in place, and the patient was transferred to a tertiary … The patient would ask the nurses to "push the hydromorphone fast" and flush after the medication (saying … approach will be carried over to hospital admissions (excepting indications necessitating a short-term change … Perspective What We've Learned About Leveraging Leadership and Culture to Affect Change … Perspective Our Maturing Understanding of Safety Culture: How to Change

3183. The Physical Environment: An Often Unconsidered Patient Safety Tool | PSNet
      psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
      November 21, 2018 - enactment of the Affordable Care Act, the entire health care industry has additional incentive to address … As seen in the Figure , environmental latent conditions undermine system defenses, setting the stage … Below, we discuss some of the key findings from the Pebble partners as they relate to patient safety … be impacted by the design? … The impact of the environment on infections in healthcare facilities.

3184. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33642/psn-pdf
      November 01, 2006 - the effects of the drugs on the patient. … The intelligence is all in the designer. … Then maybe we could change the situation. … They do not simplify your task, they change your task. So instead of doing x, you're now doing y. … The technology changes the nature of the job.

3185. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49866/psn-pdf
      June 01, 2019 - the patient on inhalational anesthesia, the consultant stepped out to tend to another patient in the … In the operating room, the patient's heart rate dropped below 50 beats per minute, and the resident … The resident was reluctant to administer the drug without verifying the product, but the anesthesia … As the resident injected the drug, the consultant returned to the operating room. … the contents of the syringe.

3186. WebM&M: Case Studies | PSNet
      psnet.ahrq.gov/webmm-case-studies
      March 25, 2025 - Hospitalists (4) Intensivists and Other ICU Strategies (2) Specialized Teams … The commentary discusses the contraindications for beta-blockers in the setting of acute decompensated … During the first follow-up visit, the surgeon did not address the situation, so the patient brought it … up at the end of the visit. … The clinician promptly corrected the error by administering the appropriate dose of rocuronium.

3187. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.158_slideshow.ppt
      September 01, 2007 - from appearing on the EMAR. … 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 seemed more than usual. … Although the overdosage was noted at that time, the administration of the incorrect drug (Neurontin, … The admitting physician and nurse failed to review the anesthesiology records or reconfirm the PAML with

3188. In Conversation with...Lucian Leape, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-withlucian-leape-md
      August 01, 2006 - I was always interested in how to change things and make the world a better place, but I guess everybody … 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 … culture change in situations in which the survival of the individuals is not directly threatened (as … we didn't call them that then), financial incentives to motivate change (largely in the form of high

3189. In Conversation with...Bradley T. Rosen, MD, MBA | PSNet
      psnet.ahrq.gov/perspective/conversation-withbradley-t-rosen-md-mba
      March 01, 2008 - We've slowly added to our "menu" over the years based on the needs of the referring physicians and the … It's not as if the Procedure Center started providing the service to half the hospital and left the other … The nurse also helps to clean up afterward, helps collect the data, and helps to move the cart and the … 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

3190. Statewide Telehealth Program Enhances Access to Care, Improves Outcomes for High-Risk Pregnancies in Rural Area | PSNet
      psnet.ahrq.gov/innovation/statewide-telehealth-program-enhances-access-care-improves-outcomes-high-risk
      November 13, 2024 - the innovation. … Updates include updating the name of the innovation, additional programs and services offered under the … and patients across the state with UAMS, where the vast majority of the state's high-risk pregnancy … Key elements of the program include the following: Call center:  The call center, staffed by women's … The medical center, the Arkansas Department of Human Services, and the Arkansas Medical Society united

3191. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865778/psn-pdf
      May 29, 2024 - The dialysis team was called into the ED, and the consulting nephrologist started to place a temporary … This patient arrived at the hospital with pulmonary edema and kidney failure; the on-call nephrologist … Louis underwent root cause analyses by multidisciplinary teams; all involved urgent and complex procedures … In the great majority of these and other cases (albeit not the case reported here),14,15 loss of the … the number of attempts and resulting distractions, reduce the number of guidewires on the operating

3192. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73456/psn-pdf
      June 30, 2021 - room, but the anesthesiologist assigned to the case rejected the suggestion. … The anesthesiologist gave the patient rocuronium and sevoflurane, but he still could not intubate the … The primary responsibility for ensuring the adequacy of the patient's oxygenation and ventilation during … One of the issues with not having advanced airway equipment in the operating room is that the anesthesia … System issues are often latent factors that are difficult for frontline personnel to change and may

3193. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33841/psn-pdf
      September 01, 2017 - The model for this is called the ASIAS. It's in the airline industry; the FAA interacts with it. … But the federal government also has the ability to incent and therefore move the market and change the … yet how this pivot away from transactional fee-for-service care [to value-based care] is going to change … We are doing small tests of change. … Sometimes good ideas take a while to germinate, especially when there is a substantial amount of change

3194. Spinal Epidural Abscess | PSNet
      psnet.ahrq.gov/web-mm/spinal-epidural-abscess
      November 13, 2019 - The patient was taken to the operating room for drainage of the abscess. … Subsequent review of the initial MRI to determine why the lesion was initially missed found that the … We also do not know whether the back pain is more located in the lower back or in the thoracic area, … The Improving Diagnosis In Medicine Change Package can be used as a framework for setting up organizational … Improving Diagnosis in Medicine Change Package.

3195. In Conversation With... Remle P. Crowe, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-remle-p-crowe-phd
      May 16, 2022 - measures for improvement, it has to be something that happens with enough frequency, that if we make a change … , we're going to be able to see whether or not a change has resulted in any actual improvement. … , PDSA [plan do study act] cycles, looking at ways to change our culture around lights and sirens, and … change in traffic pattern. … include that they are reactive, difficult to use for trending and benchmarking, and not conducive to change

3196. Identifying Safety Events in the Prehospital Setting | PSNet
      psnet.ahrq.gov/perspective/identifying-safety-events-prehospital-setting
      May 16, 2022 - include that they are reactive, difficult to use for trending and benchmarking, and not conducive to change … among staff, to getting a baseline assessment of culture, to examining trends over time, to measuring change … , we're going to be able to see whether or not a change has resulted in any actual improvement. … , PDSA [plan do study act] cycles, looking at ways to change our culture around lights and sirens, and … change in traffic pattern.

3197. Which Line: Ordering Provider or Proceduralist? | PSNet
      psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
      September 16, 2015 - The error was disclosed to the patient, the tunneled catheter was removed, and the appropriate catheter … In the current case, the patient was harmed by having the incorrect catheter placed, but the error was … no change in imaging ordering after implementation.( 16 ) In contrast, when coupled with barriers to … this case, for the use of the line. … Impact and culture change after the implementation of a preprocedural checklist in an interventional

3198. In Conversation with...Geri Amori, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-withgeri-amori-phd
      December 01, 2010 - RW: What are the forces that you see that have led to this major change in the way the C-suite, for … RW: You've highlighted the education that was necessary in the C-suite and the change in focus and mental … expanding their roles to full enterprise risk management to look at where changes in one area affect change … the local community in the media. … The Report of the Harvard Medical Practice Study to the State of New York.

3199. The Media’s Role in Patient Safety | PSNet
      psnet.ahrq.gov/perspective/medias-role-patient-safety
      April 27, 2022 - have undergone profound change. … involvement could radically change over the next five years. … KH: So what is the overall takeaway regarding media’s influence to drive change? … The reflection in the media motivates change. … Organizational change in the face of highly public errors—I.

3200. In Conversation with…William B. Munier, MD, MBA | PSNet
      psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba
      July 01, 2011 - the U.S. … What this does for the people doing the analysis, and for the institutions where they work, is create … The first is that if you only define it at the national level and don't specify the details necessary … So to some extent, the increasing automation of everything has on the one hand offered the opportunity … CHPSO easily complied with the listing requirements, and became the second listed PSO in the nation.