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Showing results for "the change teams".

3221. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event | PSNet
      psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
      July 01, 2017 - 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

3222. Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia | PSNet
      psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
      January 29, 2021 - error rate, and the self-reported medical error rate did not change after implementation . … first-year residents in 2011 ; this change was associated with decreased risk of motor vehicle crash … involvement and needlestick injury, 21 but no change in patient experience or 30-day mortality or … the world. … The label of every ampule should display the name and the concentration of the drug in lettering large

3223. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74830/psn-pdf
      June 01, 2022 - The collaborative model is intended to support robust data collection and the sharing of best practices … 0.48% (127 out of 26,422 participants in studies included in the meta-analysis).4 Additionally, the … Innovative Activity The PICC Use Initiative began as HMS member hospitals voiced concerns over the … Context of the Innovation The innovation took place in the context of increased use of PICCs, with more … Certain approaches, such as the use of vascular access teams, have shown promise in reducing adverse

3224. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49719/psn-pdf
      September 01, 2014 - When the attending anesthesiologist took over the case at the end of the certified registered nurse … line for heart rate and oxygen saturation (indicating no change over time) and a blank space for the … in the OR, and the CRNA was unfamiliar with the menu and knobs. … The anesthesia record was manual, and the CRNA kept documenting the same reading for a whole hour. … least show their age, and the device also could have alerted the CRNA to the fact that the blood pressure

3225. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74253/psn-pdf
      January 12, 2022 - Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic January … Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic. … Throughout the field, research evaluating the impact of COVID-19 on the safety of care has revealed … alert when the patient is in isolation, or due to the time required to don the necessary PPE.6 There … As healthcare personnel have sought to innovate in their approaches, their leadership teams have been

3226. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50927/psn-pdf
      February 21, 2020 - challenges, including the types of error and the wide variety of patient populations that may be affected … that have contributed to the opioid epidemic and the rise of antibiotic resistant infections.[4],[5 … patients are hospitalized to ensure primary care clinicians are able to communicate with hospital teams … Explicit agreements on the roles and responsibilities surrounding patient care between the primary care … and the patient.

3227. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49576/psn-pdf
      January 01, 2009 - The next day, when the patient was clinically stable, the cardiologist considered transferring him back … The Commentary This case raises a key question: Did the decisions by EMS to take the patient to Hospital … On the other hand, transferring care between physicians can sometimes change management for the better … When the ED is boarding admitted patients, the remaining beds saturate. … The physician directed the patient to a facility that was farther away (where the patient's doctor was

3228. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49711/psn-pdf
      June 01, 2014 - On the morning of hospital day 6, the patient was feeling "cooped up" and "needed a change of scenery … Some patients become claustrophobic in the hospital and are simply motivated by the need to have a change … , as an element of each initial and annual evaluation for outpatients, and when a change in mental status … A unit log is maintained with the time the patient obtained the pass and time of return to the unit. … The further outside beyond the walls of the HCF, the more the risks increase.(9) Other institutions

3229. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49604/psn-pdf
      June 01, 2010 - The patient underwent uncomplicated removal of the infected stent and graft repair of the aorta. … The patient was placed on the OR schedule for the following day. … the day, including the catheter removal, so all of them were aware of the plan. … Unfortunately, because of prolonged surgeries, the case was pushed to the end of the day. … the drain while the patient was awake in the preoperative area.

3230. Handoffs and Transitions | PSNet
      psnet.ahrq.gov/perspective/handoffs-and-transitions
      February 01, 2007 - been enormous numbers of handoffs in health care delivery organizations (e.g., between nurses at shift change … of the hazards of handoffs. … the handoff process between providers in the hospital setting. … Unfortunately, the results of the studies served mostly to reinforce the notion that there is no magic … The review below focuses on some of the highest impact studies in this area.

3231. Secured But Not Always Safe | PSNet
      psnet.ahrq.gov/web-mm/secured-not-always-safe
      October 01, 2015 - However, while in recovery, the patient's family noted an increase in the size of the patient's neck, … In retrospect, the clinicians felt that the infection resulted from a perforation caused by the LMA. … The device's cuff is then inflated, after which it compresses the opening of the esophagus to secure … the airway. … Typically, specific airway management is not discussed, as the plans may change based on unexpected difficult

3232. Misread Label | PSNet
      psnet.ahrq.gov/web-mm/misread-label
      August 28, 2024 - Prompted by the proximity of the deterioration to the administration of the naloxone the physician checked … the packaging of the drug. … the brand name for naloxone, or simply because the name on the packaging was misread, there would be … In addition to exploring why the error occurred at the level of individuals at the "sharp end," such … The investigation aims to identify contributing factors at the level of the institution, organization

3233. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33659/psn-pdf
      October 01, 2007 - the behavior of others, and the culture at the point of care, or team culture. … he/she does not see the risk or feels that the benefit of the chosen behavior outweighs the risk (e.g … The error in this scenario is administering the medication to the wrong patient. … She enters the room, observes the patient sleeping, and decides not to wake the patient to check the … Just culture principles will help you change your organizational culture.

3234. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865413/psn-pdf
      March 27, 2024 - the current and the evolving threat methodology? … The IT team maintains the “firewall” and typically leads the training for the front lines to protect … the company. … They will threaten to publish the data on the internet and sell it on the dark web. … The labs may be disrupted, and the EHR will go down.

3235. Becoming a Patient Safety Organization | PSNet
      psnet.ahrq.gov/perspective/becoming-patient-safety-organization
      July 01, 2011 - CHPSO easily complied with the listing requirements, and became the second listed PSO in the nation. … One of the key aspects of the PSQIA is that it implements the Institute of Medicine's recommendation … 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

3236. Advancing Patient Safety Through State Reporting Systems | PSNet
      psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
      June 01, 2007 - Patient safety improvement requires both internal and external pressure to drive change. … institutions may already report errors internally and analyze them for lessons and opportunities for system change … Transparency In discussing the need to foster innovation and improve the delivery of care, the IOM … Crossing the Quality Chasm: A New Health System for the 21st Century. … Child August 31, 2022 Using behavioral insights to strengthen strategies for change

3237. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_intraoperative_awareness_during_rhinoplasty_slides_final.pptx
      January 01, 2024 - The patient also felt that the breathing tube was pushed up against the inside of her throat, impeding … first follow-up visit, the surgeon did not address the situation, so the patient brought it up at the … The surgeon seemed surprised and embarrassed that the patient remembered waking up during the operation … If the patient moves unexpectedly during the procedure, the surgeon should stop cutting or manipulating … on the head or neck is associated with the risk of unintentionally kinking the ETT.

3238. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33849/psn-pdf
      January 01, 2018 - You're in the team room and you hear the person next to you just flying across the keyboard. … the billing rules are stupid, and chances are the neuro exam didn't change. … The interns and the residents came in the next day, and I told them about the patients. … But before we finalize the plan, let's go examine the patient, get the story from her. … the lungs and the heart and look at the neck veins.

3239. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49771/psn-pdf
      July 01, 2016 - The intern caring for the patient was rotating at this hospital for the first time and was new to the … The next day when they reviewed the images and saw evidence of both kinds of contrast, the team recognized … the error. … than the one intended (for example, if the user is standing but the screen is at sitting height, the … parallax effect can change the apparent position of an object depending on the sight line of the viewer

3240. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia | PSNet
      psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia
      January 29, 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 be