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Showing results for "the change teams".

3321. Clostridium Difficile Relapse Secondary to Medication Access Issue | PSNet
      psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue
      October 01, 2015 - The patient contacted her primary care physician, and over the next 4 days, the nurses at the patient's … The independent pharmacy filled the oral vancomycin solution, which was delivered to the patient, and … However, after the second discharge the inpatient pharmacist was contacted by the pharmacist at the patient's … the first discharge, potentially avoiding the patient's return of symptoms, the readmission, and the … to change with the introduction of novel antibiotics, adjunct therapies, and vaccinations in clinical

3322. In Conversation with...Albert Wu, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph
      February 26, 2025 - 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 country … 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.

3323. To Transfer or Not to Transfer | PSNet
      psnet.ahrq.gov/web-mm/transfer-or-not-transfer
      November 23, 2016 - Case Objectives Explore the benefits of the continuity of hospital care. … 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 … The physician directed the patient to a facility that was farther away (where the patient's doctor was

3324. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33668/psn-pdf
      May 01, 2008 - He is the Board Chair of the American Medical Informatics Association (AMIA), a member of the Institute … Bates is one of the world's preeminent researchers in the areas of medication safety as well as the … records goes to the purchasers and the payers. … DB: Well, I think that the market is ripe for change and that we could see a large company like a Microsoft … avoid using proprietary data structures, and that has required a lot of health care IT companies to change

3325. Safeguarding Diagnostic Testing at the Point of Care | PSNet
      psnet.ahrq.gov/web-mm/safeguarding-diagnostic-testing-point-care
      September 30, 2011 - The patient provided a urine sample to the nurse. … The physician informed the patient and then placed the IUD during the same visit without complication … At the end of her shift, the nurse manually entered the results of all point-of-care tests performed … the error and immediately corrected the medical record. … The key steps are as follows: Ensure that both the provider and the individual performing the test

3326. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49798/psn-pdf
      July 01, 2017 - The next step in treatment was colonoscopy with the goal of decompressing the dilated colon. … At the beginning of the procedure, the gastroenterologist inserted the colonoscope and began insufflation … Guidelines for the role of colonoscopy in the management of ACPO were published by the American Society … Abdominal radiographs should generally be obtained at least daily, and more frequently if there is a change … The anticipated benefit of performing the procedure should outweigh the risks, which must be clearly

3327. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/847934/psn-pdf
      April 26, 2023 - , and the establishment of operational systems and processes that minimize the likelihood of errors … The Measurement of Patient Safety primer describes the framework for measuring patient safety based … In this way, users can monitor the effectiveness of their safety improvement efforts and compare the … The original efforts to assess harm in health care applied the concept of “medical error,” which Brennan … healthcare organizations attempt to address metrics such as PSIs, by creating separate quality improvement teams

3328. In Conversation with...James P. Bagian, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
      September 01, 2006 - My goal when I came here was to change the culture. … Can health care organizations really change? … Luckily, a change agent arrived in 1994 in the form of Ken Kizer. … to change than VA, aiming for the same goals. … The EHR system, CPRS, gave providers a powerful tool for change.

3329. Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees | PSNet
      psnet.ahrq.gov/web-mm/supervision-and-entrustment-clinical-training-protecting-patients-protecting-trainees
      February 22, 2017 - The ICU attending assigned the intern to transport the patient with the bedside nurse. … The patient was transported to the MRI scanner. … The chief resident had identified a medical student to sit in the scanner with the patient. … The medical student remained for the 2-hour scan and helped transport the patient back upstairs. … Entrustment as assessment: recognizing the ability, the right, and the duty to act.

3330. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality | PSNet
      psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
      October 01, 2004 - The next day, the patient reported that her pain was worse, and the team noted an 8-centimeter hematoma … there is improvement in the documentation of the process but not in the actual process itself. … The second concern expressed about the public reporting of quality data relates to the phenomenon of … hospitals must recognize that unintended consequences are bound to occur following any effort to implement change … August 30, 2006 Perspective Organizational Change in the

3331. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60744/psn-pdf
      July 29, 2020 - The inpatient medicine team obtained a “curbside” cardiology consultation; the consultant felt that … The patient’s prior history of CAD and STEMI with stent placement to the LAD greatly increased the pretest … In the patient in this case, community acquired pneumonia (CAP), evidenced by the patient’s dyspnea … magnitude of the stressor and the extent of underlying cardiac disease,22 so testing to assess the … to the consulting cardiologist.

3332. In Conversation with...Joseph Britto, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-withjoseph-britto-md
      February 01, 2007 - The company has been profiled in the Wall Street Journal , and the system has undergone several validation … 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. … 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

3333. Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing | PSNet
      psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk-medications-potentially-complex-dosing
      August 21, 2005 - Systems Change Needed/Quality Improvement Approach  Medical care is complex and best practices frequently … change, making it difficult for providers to keep up with the most current evidence-based and FDA-approved … change on the correct day. … is not available, then clear written instructions and specific dates, e.g. for the dose change, should … date(s) when the change in dose should take place. 

3334. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49738/psn-pdf
      August 21, 2015 - In this case, the patient requiring the brain MRI had the same initials as another patient on the same … The cross-covering resident mixed up the two patients and placed the MRI order in the wrong chart. … The following morning, the primary team caught the error and the MRI was canceled and ordered for the … The context of the law was important. … The Importance and Value of Protecting the Privacy of Health Information: The Roles of the HIPAA Privacy

3335. Triaging Interhospital Transfers | PSNet
      psnet.ahrq.gov/web-mm/triaging-interhospital-transfers
      April 12, 2023 - The physician noted the presence of high fevers and headache, and so he sent the patient to the emergency … The colleague secured a bed through the bed control department and suggested he send the patient over … In reviewing the case, the accepting physician was not aware of how critically ill the patient had become … may have correctly triaged the patient to the ICU) were bypassed. … The development of the patient transfer center at Ochsner Medical Center.

3336. Critical Opportunity Lost | PSNet
      psnet.ahrq.gov/web-mm/critical-opportunity-lost
      February 17, 2017 - test the following morning. … The case was reviewed by the hospital's quality committee, whose members noted that the providers in … test and if applicable, the individual responsible for using the test results … the lists, policies, and procedures that were in place at the time of the incident and then evaluate … The provider could then review and acknowledge receipt of the critical value.

3337. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49784/psn-pdf
      February 01, 2017 - The patient provided a urine sample to the nurse. … The physician informed the patient and then placed the IUD during the same visit without complication … At the end of her shift, the nurse manually entered the results of all point-of-care tests performed … the error and immediately corrected the medical record. … The key steps are as follows: Ensure that both the provider and the individual performing the test are

3338. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33639/psn-pdf
      September 01, 2006 - JB: Well, the biggest thing was the culture. … My goal when I came here was to change the culture. … It was that other physician, that other nurse, the other floor, the hospital down the street, yeah, … That's a big sea change for people to think about, but it makes sense. … But then they do the lion's share of the work.

3339. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49646/psn-pdf
      February 01, 2012 - to the complexity and acuity of the patient's medical conditions. … One afternoon, the patient presented to the emergency department (ED) and was admitted to the hospital … During the hospitalization, the primary team engaged the patient and his family in advanced directive … The change in code status was communicated to the patient's primary physician. … to the community.

3340. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49569/psn-pdf
      September 01, 2008 - In addition, the chest radiograph showed the nasogastric tube had moved again, and the tip was now in … the esophagus. … Given the more proximal location of the nasogastric tube, physicians felt that the pneumonia was most … the ICU. … We are told that the NG feeding tube had migrated from the patient's small bowel into the esophagus.