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Showing results for "the change teams".

3261. In Conversation With... Cindy Brach | PSNet
      psnet.ahrq.gov/perspective/conversation-cindy-brach
      December 27, 2019 - CB : I’m the Co-Chair of the HHS Health Literacy Workgroup. … minimal context about the care of the patient. … With the CLAS Standards, the Office of Minority Health set out to answer the question: What do I do if … The Standards operationalize the definition. … competence training programs aim to increase cultural awareness, knowledge, and skills, leading to behavior change

3262. In Conversation With… Hardeep Singh, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-hardeep-singh-md-mph
      January 01, 2014 - When I received the news about the K12 award in 2005, I was told the committee not only liked my proposed … Investigators reviewed the records of medical patients admitted to the pediatric ward or seen in the … significant increase in the average number of phone calls in the 1 hour preceding the generation of … In the area of curricular change, it highlighted the need for medical schools to modernize their curricula … medical education as an area in need of new thinking and programs, and this trend is unlikely to change

3263. Antiseizure Medication Disorder | PSNet
      psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
      April 01, 2006 - The providers thought that the patient's mental status change was likely due to urinary tract infection … No mention is made of a medication-related change that might explain the elevated phenytoin level. … from this case, a phenytoin blood level can be quite helpful even when there is no reason to suspect a change … The common clinical dictum is "treat the patient, not the number." … August 18, 2010 WebM&M Cases Critical Order Set Change

3264. Safety and Medical Education | PSNet
      psnet.ahrq.gov/perspective/safety-and-medical-education
      December 01, 2013 - In the area of curricular change, it highlighted the need for medical schools to modernize their curricula … In the area of changing the clinical setting in which so much of medical training takes place, the report … The CLER Pathways to Excellence report describes discoveries from the first year of the program, including … At the UME level, the Association of American Medical Colleges has defined the ability to "identify system … medical education as an area in need of new thinking and programs, and this trend is unlikely to change

3265. Making Just Culture a Reality: One Organization's Approach | PSNet
      psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach
      October 01, 2007 - he/she does not see the risk or feels that the benefit of the chosen behavior outweighs the risk (e.g … 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. … alerts in hospital CPOE systems to change prescriber behavior and improve patient safety. … October 1, 2007 Perspective Organizational Change

3266. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846935/psn-pdf
      March 29, 2023 - Analyses from the U.S. … the health continuum. … need.3 Providing education to the entire care team, including the patient and the patient’s support … for tracking improvement to help influence decisions by care teams. … in the long term to enhance our understanding of the full impact of mental health on both the mother

3267. Patient Mix-Up | PSNet
      psnet.ahrq.gov/web-mm/patient-mix
      December 01, 2007 - Moreover, the admission occurred at 6:30AM, around the time the nursing shift changed, so that the outgoing … The nurse retrieved the pre-filled syringe from the correct Mr. … the medical student in the room at the time of medication administration and the student's fortunate … the medication room, in the pharmacy, on the door to the patients' rooms or other places relevant to … June 22, 2022 Expanding the scope of Critical Care Rapid Response Teams: a feasible approach

3268. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33701/psn-pdf
      October 01, 2010 - Any system has the power to complicate or assist—the design of the checklist determines its utility. … The first step in task decomposition is task analysis, which takes many forms based on the goal of the … If both hands are used in the task, the checklist cannot require the use of hands, or the steps need … In the implementation of the WHO surgical checklist, pauses were built into the checklist.(3) These … the airplane.(13) Test the checklist.

3269. Missed TB | PSNet
      psnet.ahrq.gov/web-mm/missed-tb
      March 03, 2010 - The Case A 38-year-old white female with no past medical history presented to the hospital with fevers … The treating physicians considered bronchoscopy, but felt the patient was too ill to tolerate the procedure … The AFB smears were negative. … same period.( 2 ) The mortality rate of 69% was higher than the mortality for respiratory failure due … to confirm the diagnosis.

3270. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49851/psn-pdf
      January 01, 2019 - The entire care team paused in real time to review the events. … The critical care provider noticed that the syringes that contained the different fluids were not labeled … Fortunately, the patient did not experience any adverse consequences from the use of the lidocaine for … The patient remained intubated until the midazolam wore off. … could have led to a change of treatment not benefiting the patient.

3271. If You Say So: Taking a Syringe at Face Value in the Operating Room | PSNet
      psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room
      January 01, 2015 - the patient on inhalational anesthesia, the consultant stepped out to tend to another patient in the … The resident was reluctant to administer the drug without verifying the product, but the anesthesia technician … As the resident injected the drug, the consultant returned to the operating room. … the contents of the syringe. … The appropriate action would have been to hand the medication vial directly to the resident.

3272. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33745/psn-pdf
      February 01, 2013 - In just the past few months, the Commonwealth Fund reported a striking degree of international variation … in the extent to which patients reported engagement in their own care (1), the Agency for Healthcare … Effective engagement implies that patients have the opportunity to assess the care they receive, with … adverse events that took place during the hospitalization as health professionals who reviewed the … Several hospitals have implemented programs that allow patients or families to activate rapid response teams

3273. Delayed Sepsis Management Due to Ambiguous Allergy | PSNet
      psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy
      January 13, 2021 - On the day of presentation, the patient arrived at the infusion center for a scheduled platelet transfusion … , the delayed antibiotic administration likely contributed to the death. … If there is no reaction, then the penicillin allergy is deleted from the record. … Redesigning the allergy module of the electronic health record. … March 1, 2019 WebM&M Cases Critical Order Set Change

3274. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. | PSNet
      psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-postoperative-cervical-hematoma
      August 14, 2024 - The patient was discharged to a hotel across the street from the hospital, where a one-night stay had … The following morning, the patient called the surgery clinic to report increased neck pain and swelling … Surgical and anesthesia teams should work together to ensure a plan for airway access, as hematoma evacuation … effort to evacuate the hematoma and secure the airway in the controlled environment of the operating … – in many cases, at the bedside, before the airway is secured.

3275. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49682/psn-pdf
      April 01, 2013 - Subsequent review of the case, including the clinical documentation, noted that the provisional diagnosis … vasculitis during the ensuing outpatient follow-up, in both the minds of the clinicians and the chart … Neuroimaging was the correct choice of subsequent diagnostic tests, but the CT scan of the brain was … about the incorrectness of the working diagnosis. … "When the diagnosis is made, the thinking stops."

3276. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/843051/psn-pdf
      February 01, 2023 - The patient was discharged to a hotel across the street from the hospital, where a one-night stay had … The following morning, the patient called the surgery clinic to report increased neck pain and swelling … Surgical and anesthesia teams should work together to ensure a plan for airway access, as hematoma evacuation … effort to evacuate the hematoma and secure the airway in the controlled environment of the operating … – in many cases, at the bedside, before the airway is secured.

3277. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866261/psn-pdf
      July 10, 2024 - stirrup and the fibula.1 The legs should therefore be placed on the outside of the stirrup rather than … For each centimeter that the ankles are elevated above the heart, the arterial pressure in the calf … They elevate the pressure transducer of the arterial line to the level of the ear to measure and record … The calf muscles, however, are not given the same priority as the brain. … The more extreme the lithotomy and Trendelenburg positions, the higher the https://psnet.ahrq.gov//#15

3278. In Conversation With… Suchi Saria, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-suchi-saria-phd
      March 27, 2024 - The further I went in the field, the more exciting it became. … As I walked through the floors of the NICU, I said to Anna, "All this data on the monitors looks like … Similarly, I didn't understand at the time that to use the data we needed the right infrastructure. … In both parties, the predicament is that things could be learned about the work from the data that we've … I'd like to change that.

3279. Low on the Totem Pole | PSNet
      psnet.ahrq.gov/web-mm/low-totem-pole
      October 01, 2003 - from the patient’s creatinine level to the concerns of the patient’s family. … In fact, the usual hierarchy in the medical workplace, with physicians at the top of the heap, is set … On rounds, the student presented this new data, including the account of the Foley placement in the OR … The second attending told the student this information should have been conveyed at the time of the incident … Shortly thereafter, the student submitted a report outlining the events in the OR to the institutional

3280. Code Status Confusion | PSNet
      psnet.ahrq.gov/web-mm/code-status-confusion
      September 01, 2006 - 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 patient … 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