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Total Results: 3,566 records

Showing results for "the change teams".

3341. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/845473/psn-pdf
      March 15, 2023 - Over the years, telehealth has rapidly evolved with the continued advancement in available technology … The implementation of electronic health records (EHRs) and expanded access to the internet and medical … course of the PHE. … hospital utilization and detecting any change in status of patients. … Federal Communications Commission and at the Office for the Advancement of Telehealth at the Health

3342. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866579/psn-pdf
      August 28, 2024 - There were no reported complications during the operation, and the patient was discharged from the hospital … the same day. … The surgeon also told the patient not to soak her hand in water, which would reduce the risk of infection … The patient contacted the surgeon’s office and spoke to the medical assistant (MA), but no action was … (MAs) are being given expanding roles in supporting care teams.31–33 The person answering the patient

3343. Infection After Carpal Tunnel Surgery | PSNet
      psnet.ahrq.gov/web-mm/infection-after-carpal-tunnel-surgery
      May 28, 2014 - the same day. … The patient contacted the surgeon’s office and spoke to the medical assistant (MA), but no action was … The MA stated that the patient never reported that the wound was red, hot, foul-smelling, swollen, or … The surgeon’s MA removed the patient’s sutures and noted that the wound was not infected or swollen. … (MAs) are being given expanding roles in supporting care teams. 31–33 The person answering the patient

3344. Intraoperative Awareness during Rhinoplasty | PSNet
      psnet.ahrq.gov/web-mm/intraoperative-awareness-during-rhinoplasty
      January 29, 2021 - The patient also felt that the breathing tube was pushed up against the inside of her throat, impeding … 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 surgeon seemed surprised and embarrassed that the patient remembered waking up during the operation … , and the tone of the frontalis muscle should be carefully monitored throughout the operation.

3345. In Conversation With… Andrew Gettinger, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-andrew-gettinger-md
      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 … know 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

3346. Right Electrocardiogram, Wrong Patient | PSNet
      psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
      April 24, 2024 - All of the cases involved the nurse or EKG technician either entering the wrong medical record number … The incorrect patient documentation on the EKG caused EKG results to be uploaded to the wrong patients … EKG diagnosis fit with the clinical history of the patient. … The physical EKG results are then usually given to the healthcare provider for review, and the electronic … In the majority of the cases, the error was detected by the nurse or clerk prior to EKG transmission

3347. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49613/psn-pdf
      November 01, 2010 - her pumped breast milk in the refrigerator on the infant's ward in the hospital. … The nurse and nurse's aide reviewed the events and suggested to the mother that the administered milk … The mother, skeptical that the milk was hers, asked that the nurses search the refrigerator. … What prompted the aide and the nurse to minimize the mother's concerns regarding the breast-milk label … It was only after the feed had begun that the RNs were alerted to the breast-milk error by the audio

3348. Baffled by Botulinum Toxin | PSNet
      psnet.ahrq.gov/web-mm/baffled-botulinum-toxin
      July 17, 2024 - The attending physician, fellow, and nurse went in the room to perform the injections. … Upon further questioning, the mother clarified that the clinicians in the urology clinic had had Botox … The scheduled injections were completed, followed by a long discussion held with the mother about the … However, after the procedure, the attending and fellow reviewed the electronic medical record (EMR) in … Proper documentation and communications between the treating teams about the botulinum neurotoxin injections

3349. Delayed Diagnosis in the Setting of Virtual Care: Remembering the Physical Examination | PSNet
      psnet.ahrq.gov/web-mm/delayed-diagnosis-setting-virtual-care-remembering-physical-examination
      April 29, 2020 - The physician also noted that the patient described a skin breakdown on her “backside,” but the affected … The plan was for a home health nurse to evaluate the skin breakdown later in the week. … Therefore, the rapid breathing, diarrhea, and sweating experienced by the patient in this case on the … , as the perianal space is continuous with the fat of the buttock. 9  The case does not specify the location … Telehealth: The Right Care, at the Right Time, via the Right Medium.

3350. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/852807/psn-pdf
      August 30, 2023 - error rate, and the self-reported medical error rate did not change after implementation. … residents in 2011; this change was associated with https://psnet.ahrq.gov//#1 https://psnet.ahrq.gov … new-recommendations-duty-hours-acgme-task-force decreased risk of motor vehicle crash involvement and needlestick injury,21 but no change … The label of every ampule should display the name and the concentration of the drug in lettering large … Fatigue on the flight deck: the consequences of sleep loss and the benefits of napping.

3351. Diagnostic Errors | PSNet
      psnet.ahrq.gov/perspective/diagnostic-errors
      December 01, 2013 - Whatever the explanation for the relative inattention to diagnostic errors within the field, a commentary … 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 … The authors structured the cases such that some were simple and some complex, and so that the salient … distracting feature appeared either near the beginning of the case description or closer to the end.

3352. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867804/psn-pdf
      February 26, 2025 - The studies utilized methodology current to the time. … used in both the Harvard Medical Practice Study and the Utah and Colorado study. … Current Measures of Adverse Events The Safe Care study sought to return to the goals of the original … little change in infection rates, despite efforts to reduce them. … research from the National Institutes of Health (NIH) and the CDC advanced scientific knowledge on the

3353. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33882/psn-pdf
      June 01, 2019 - However, the absence of reportable incidents does not mean that everything is going well, and the occurrence … When an incident or error does occur, aspects of work are analyzed through the lens of the negative … engineering strives to enhance the system's capabilities identified within the resilience framework … fundamentals of the resilience engineering approach—specifically, the need to focus on how safety is … The following are some of the key challenges that influence the implementation of a resilience engineering-based

3354. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49425/psn-pdf
      November 01, 2003 - 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

3355. Rediscovering the Power of the Surgical M&M Conference: The M M Matrix | PSNet
      psnet.ahrq.gov/perspective/rediscovering-power-surgical-mm-conference-mm-matrix
      September 01, 2007 - Rediscovering the Power of the Surgical M&M Conference: The M+M Matrix Leo A. … I refer to the iconic gathering that so readily evokes the surgical "days of the giants": the traditional … recognize that we are not as good as we would like to be, our inherent professionalism will motivate us to change … We have now seen several examples of effective things you can do that really change complication rates … August 10, 2005 Perspective Organizational Change in the

3356. Missing the Point—Eye Injury | PSNet
      psnet.ahrq.gov/web-mm/missing-point-eye-injury
      March 01, 2005 - asked her if she noted any change in her vision (which she did not). … The ED provider everted the lid (turned it up to see underneath) and the laceration did not appear to … 7 mm into the sclera (globe of the eye). … Eye complaints that present to the ED can be broken down into three major categories: the red eye, the … into the fluid inside the eye).

3357. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33712/psn-pdf
      June 01, 2011 - In the case of seatbelts and other road technology, I just read in The New York Times about how the … We may be too much in the middle of the soup. … the effects of the Exxon Valdez spill. … ability to get things done, everything depended on the attitudes and the values of the people at the … through in health care, and we're trying to figure out how to change it.

3358. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49529/psn-pdf
      February 01, 2007 - The intern did not write the order for warfarin for hospital day two and clearly outlined in the daily … After the shift change, the evening nurse noted that the daily warfarin order had not been written. … Without checking the progress notes or the patient's INR level for the day, the cross-covering intern … The pharmacy dispensed the medication, and the patient received 15 mg of warfarin. … respond to either a threshold INR or change in INR of a predetermined magnitude.(12) Finally, a dedicated

3359. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49620/psn-pdf
      February 01, 2011 - Over the next few hours, the patient's symptoms persisted, and he noted the onset of mild dysphagia. … The nurse contacted the in-house intensivist, who evaluated the patient and once again found no evidence … An emergent tracheostomy was performed at the bedside and the patient was transferred to the intensive … However, nonspecific symptoms such as change in voice quality, neck tightness, neck pain/pressure, neck … Nonspecific symptoms such as change in voice quality, neck tightness, neck pain/pressure, neck swelling

3360. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.323_slideshow.ppt
      May 01, 2014 - This presentation is based on the May 2014 AHRQ WebM&M Spotlight Case See the full article at http:// … She underwent an uncomplicated surgical resection of the colon with relief of the obstruction. … They spoke directly with the family and reviewed the official medication reconciliation list, which had … Based on this discrepancy, the consulting service contacted the outpatient pharmacy and learned the patient … She had not been prescribed the drug during the hospital stay, and the last patch had been placed more