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Showing results for "the change teams".

3241. Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy | PSNet
      psnet.ahrq.gov/web-mm/perioperative-anaphylaxis-after-insertion-latex-drain-patient-known-latex-allergy
      July 08, 2022 - The Commentary By Kevin J. … Systems Change Needed/Quality Improvement Approach When the incidence of latex allergy was first noted … to enter the patient room. … The purchasing process and the product choice process (on the patient care unit) should be engineered … The role of allergen components for the diagnosis of latex-induced occupational asthma. 

3242. Hard to Swallow | PSNet
      psnet.ahrq.gov/web-mm/hard-swallow
      April 26, 2023 - The physician did not see the form, and the patient continued to receive thickened liquids. … completion of the diagnostic evaluation (ie, if the patient were made NPO pending the outcome of the … therapist to communicate the need to change the diet orders in a more timely and direct fashion than … the primary team to do the same. … This effectively reduces the possibility of aspiration from the time of the physician's order to the

3243. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49411/psn-pdf
      July 01, 2003 - The resident had discussed the case briefly with the intern (including her interpretation that the patient … wished to be a DNR), but neither the resident nor the attending had discussed code status with the … The following day, the patient was alert and was able to express her thoughts about the events of the … The real lesson here is that the housestaff should have acted on that intuition at the time of the original … In this case, the outpatient attending physician may have said that the refusal was not like the patient

3244. Returning Home Safely | PSNet
      psnet.ahrq.gov/web-mm/returning-home-safely
      December 22, 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 felt … Interdisciplinary teams of nurses, social workers, and rehabilitation therapists are ideally positioned

3245. Improving Diagnostic Safety and Quality | PSNet
      psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
      January 31, 2024 - Other research highlighted the variability in the extent to which these factors, or the interaction of … (i.e., the risk of antimicrobial resistance) outweighed the risk of treating the individual unnecessarily … These barriers may be difficult to change, such as reimbursement models based on patient volume, or they … Improving Diagnosis in Medicine Change Package . Health Research & Educational Trust; 2018. … https://www.improvediagnosis.org/improving-diagnosis-in-medicine-change-package/#:~:text=The%20Improving

3246. In Conversation With... James Augustine, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-james-augustine-md
      July 28, 2021 - That’s just the beginning of the process. … The same with stroke, the same with acute MIs, the same with delivering babies, the same with very sick … that the extrication of the patient took place; that the patient was transported; and that the EMS personnel … and to really take the care to the people. … Following the 911 call, the 911 center personnel must triage the call to ensure that, based on the information

3247. In Conversation with...Barbara Pelletreau and John Riggi about Cybersecurity | PSNet
      psnet.ahrq.gov/perspective/conversation-withbarbara-pelletreau-and-john-riggi-about-cybersecurity
      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 … They will threaten to publish the data on the internet and sell it on the dark web. … First and foremost, executive leadership teams need to devote time and resources to this concern and … However, developing these plans is only the first step; they must be practiced regularly with all teams

3248. Cybersecurity and How to Maintain Patient Safety | PSNet
      psnet.ahrq.gov/perspective/cybersecurity-and-how-maintain-patient-safety
      March 27, 2024 - First and foremost, executive leadership teams need to devote time and resources to this concern and … However, developing these plans is only the first step; they must be practiced regularly with all teams … The cyberattack: from the POV of the CEO. Hancock Health . Published January 19, 2018. … The IT team maintains the “firewall” and typically leads the training for the front lines to protect … They will threaten to publish the data on the internet and sell it on the dark web.

3249. In Conversation With…Kaveh G. Shojania, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
      September 01, 2011 - In most of the institutions I've ever worked, both in the United States and Canada, probably the single … message about the name of the patient and why you're calling and let a SWAT team just descend on the … If the person who did the incident investigation is gone or no longer the head of the department of safety … Sometimes institutions make the mistake of not closing the loop with the incident reporter. … The arguments for the centrality and the commonality type of approach are obvious.

3250. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2021-09/spotlight_lost_in_transitions_of_care_09.22.2021_final.pdf
      January 01, 2021 - For each controlled substance prescription, the PDMP shows the date filled, the drug name and formulation … the care team, so the prescription was never filled … Compare the medications on the two lists 4. Make clinical decisions based on the comparison 5. … repeatedly prescribed the latter medication instead. 32 Insurance/Refill Barriers (2) • Care teams … higher the total daily dose (TDD) of short- acting opioids, the lower the amount of methadone that is

3251. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please | PSNet
      psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
      September 01, 2011 - In most of the institutions I've ever worked, both in the United States and Canada, probably the single … message about the name of the patient and why you're calling and let a SWAT team just descend on the … If the person who did the incident investigation is gone or no longer the head of the department of safety … Sometimes institutions make the mistake of not closing the loop with the incident reporter. … The arguments for the centrality and the commonality type of approach are obvious.

3252. In Conversation With… Vineet Arora, MD, MAPP | PSNet
      psnet.ahrq.gov/perspective/conversation-vineet-arora-md-mapp
      May 31, 2023 - do the right thing at the right time at the point of care. … We have not harnessed the principles of adult learning in medicine to drive that change. … That is driving a lot of change in medicine. … of patients holds great promise to dramatically change things. … When that starts happening in academia, that's where we will need to see a lot of change.

3253. A Fatal Twist in Pseudohyperkalemia | PSNet
      psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
      February 10, 2021 - The University of Maryland School of Pharmacy is accredited by the Accreditation Council for Pharmacy … The patient thought the pain was related to his diet and put himself on a juice cleanse one week before … by either the machine or the ED physician. … Unwinding the Case Despite the laboratory report of hyperkalemia, the patient presented with several … These findings could have prompted the physician to question the validity of the lab measurement.

3254. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49395/psn-pdf
      April 01, 2003 - In the step-down unit, the resident wrote an order for a maintenance dose of phenytoin. … As a result, the patient received approximately three times the indicated dose. … The lack of clinical consequences to the error reflected the pharmacist’s recognition of the ambiguous … The pharmacist and physician were both sued in this case – the physician for the illegible handwriting … itself and the pharmacist for not questioning the illegible prescription, especially given that the

3255. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33676/psn-pdf
      November 01, 2008 - And so we all went on the other side of the bed, lifted up the sheet, and saw that there was a catheter … : As I recall, there's a study that just came out that looked at that connection and did not find a change … in the middle of the night, they might not realize that the catheter is draining their bladder. … RW: You spoke about the challenges and maybe some of the opportunities in the new policy of not paying … , and that the large drape be either in the kit or be part of the central venous catheter kit.

3256. A Little Shuteye | PSNet
      psnet.ahrq.gov/web-mm/little-shuteye
      December 22, 2018 - The wound was close to the eye, the child squirmed during the application, and no eye protection was … After the procedure, the physician realized that the child could no longer open his eye, which had been … Overall, these last two factors have tipped the scales in favor of the use of the tissue adhesives. … the users? … , requires only an e-mail to all staff and posters in the medication room reminding staff of the change

3257. Good Night's Sleep Gone Wrong | PSNet
      psnet.ahrq.gov/web-mm/good-nights-sleep-gone-wrong
      September 01, 2015 - The Case A 64-year-old woman came to the emergency department complaining of cough and shortness of … the medical floor. … As patients age, the pharmacokinetics of many medications change due to slower metabolism and decreased … In this case, it is unclear whether the nephrologist who prescribed the hydroxyzine knew that the patient … prescriptions should also be evaluated before the patient leaves the hospital.

3258. Patient Safety in Medical, Nursing, and Other Clinical Education | PSNet
      psnet.ahrq.gov/perspective/patient-safety-medical-nursing-and-other-clinical-education
      January 31, 2020 - Over the past two decades, the competency-based evolution in education has shifted the focus to outcomes … In 2019, the Association of American Medical Colleges (AAMC) released the Quality Improvement and Patient … Safety Competencies Across the Learning Continuum report, focusing not only on the core competencies … A careful review of the existing overall curricula for ways the competencies are already being taught … Regardless of the approach chosen, organizations such as AAMC and the WHO have emphasized that teaching

3259. Transfusion "Slip" | PSNet
      psnet.ahrq.gov/web-mm/transfusion-slip
      June 14, 2011 - The alert technologist in the blood bank noticed the change in blood type and inferred that a mistake … The simultaneous arrival of two or more patients with the same surname (as in this case) adds to the … attributable to the introduction of bar coding systems.( 13 ) As is often the case, the introduction … of change as well.( 14 ) Just as intended corrections may create an illusion of safety, so may recovered … March 18, 2019 "It is not the fault of the health care team - it is the way the system

3260. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33670/psn-pdf
      July 01, 2008 - The third problem is reinventing the wheel. … It seems to me that is to some extent the crux of the problem. … The reports bear more resemblance to one another than the myriad of incidents reported all over the … The second is that there would need to be a process to convince people who could actually change things … AW: I think the horse is out of the barn.