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Showing results for "the change teams".

3361. Medication Errors and Adverse Drug Events | PSNet
      psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
      December 15, 2024 - and the patient actually receiving the medication consists of several steps: Ordering: the clinician … must select the appropriate medication and the dose, frequency, and duration. … quantity of the medication in the correct form. … Administration: the correct medication must be supplied to the correct patient at the correct time. … "Five Rights" of medication safety (administering the Right Medication, in the Right Dose, at the Right

3362. In Conversation with...Atul Gawande, MD, MA, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-withatul-gawande-md-ma-mph
      September 01, 2007 - It's still the bottom line that "The secret in caring for the patient is caring for the patient," as … recognize that we are not as good as we would like to be, our inherent professionalism will motivate us to change … AG: I told the story in the book about the 117 cystic fibrosis centers across the country, which work … We have now seen several examples of effective things you can do that really change complication rates … The discussion is channeled and refined as the moderator focuses on the patient-safety aspects of the

3363. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60328/psn-pdf
      May 27, 2020 - The patient was transferred from the PACU to the surgical floor at 20:00 where supplemental oxygen was … double-check by 2 RNs to verify proper PCA connection and settings for new administration, rate change … , assumed care, or change of shift Connection between IV and PCA should be as close to the patient … first 24 hours after surgery or between midnight and 6 am Increased sedation or change in level of … Taenzer AH PJ, McGrath SP Executive Summary: Opioid-Induced Ventilatory Impairment (OIVI): Time for Change

3364. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33724/psn-pdf
      February 01, 2012 - As such, the result has been a group of residents who do the work but intellectually don't feel on the … the patient with the resident team engaged in the care probably winds up better for the patient. … They accept whatever is the culture and the rules of the game within residency. … LS: That was the implication of the conversation. … It's different than trading the retractor for the scissors. The technology is racing ahead.

3365. Pocket Syringe Swap | PSNet
      psnet.ahrq.gov/web-mm/pocket-syringe-swap
      July 01, 2006 - During the closure of the surgical incision, the surgery fellow drew 12 mL of 0.25% bupivacaine (a local … The fellow subsequently placed the bupivacaine syringe with the remaining 8 mL of the drug in the pocket … At the conclusion of the surgical procedure, the attending asked the fellow to reverse the neuromuscular … intended drug and the one actually delivered.( 4 ) By the first definition, the present case, which … the patient was moved from the OR.

3366. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865374/psn-pdf
      March 27, 2024 - the promise that some of the challenges can be reduced or overcome. … five years.1 The successes in this specialty can be attributed to the progress and development of AI … the patient, the AI system can be listening along and completing the chart for them.8 This will not … Implementation Best Practices Capitalizing on the potential of AI and overcoming the attendant risks … Rigorous validation, responsible implementation, and continuous monitoring by multidisciplinary teams

3367. One Bronchoscopy, Two Errors | PSNet
      psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
      December 09, 2020 - 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. … The care team disclosed the errors to the patient including a commitment to making improvements to prevent … have led to a change of treatment not benefiting the patient.

3368. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33883/psn-pdf
      July 01, 2019 - Saria is the John C. … 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. … I'd like to change that.

3369. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33758/psn-pdf
      December 01, 2013 - When I received the news about the K12 award in 2005, I was told the committee not only liked my proposed … That means that there's going to be some tension between the acts of research in improvement and the … issues at the facility level. … so we don't overburden the field. … It's nice to be recognized by the scientific community too. In 2012, I received the Alice S.

3370. In Conversation with...Diane Rydrych, MA | PSNet
      psnet.ahrq.gov/perspective/conversation-withdiane-rydrych-ma
      February 26, 2025 - RW: Talk a little bit about the genesis of the system and maybe even the politics. … The legislation came from MAPS and was supported by the Medical Association, the Hospital Association … , and the Department of Health from the get go, as well as by the Governor, which probably made it a … RW: It's a little bit surprising that the hospitals would have been on board from the get go with the … what the point of the system is.

3371. Hidden Mystery | PSNet
      psnet.ahrq.gov/web-mm/hidden-mystery
      December 01, 2011 - The consulting surgeon recommended repeat abdominal imaging, but the patient was unable to fit in the … As in the non-obese patient, endotracheal intubation remains the method of choice for controlling the … Obesity increases the risk of intubation by inhibiting the physician's view of the laryngeal structures … --the evidence report. … Weighing the care: physicians' reactions to the size of a patient.

3372. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49849/psn-pdf
      January 01, 2019 - Over the course of a few hours, the hypoxia resolved but the tachycardia persisted. … On the morning of hospital day 5, the nurse found the patient to be unresponsive. … The psychiatry resident consulting in the ED and clinicians on the unit attributed the patient's tachycardia … change, which can be as high as 80% and is more likely when the patient has a mental health history … Patient handoffs occurring at transitions between providers—either across levels of care or at change

3373. Microsoft PowerPoint - Spotlight Case_Gabapentin Overdose_12.21.2022 FINAL.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-01/spotlight_overdose_of_gabapentin_and_oxycodone_in_a_patient_with_end-stage_renal_disease.pdf
      January 01, 2023 - of the gabapentin and opioids … notice the potential danger from escalating doses of these medications over several days, until the … the screen and the clinician must act on the alert to complete the workflow) …   • In the case of alerts for CKD, the EHR could instead use the most recent creatinine via a separate … of the remaining alerts

3374. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.45_slideshow.ppt
      January 01, 2004 - Review of the chest x-ray in the emergency department (ED) revealed no abnormalities. … Case (cont.): Crushing Chest Pain The patient was admitted to the cardiac care unit. … re-reviewed the chest x-ray and discovered an abnormality in the aorta: a 1-cm separation between the … intimal calcification and the adventitial outline of the descending aorta (the “calcium sign”), consistent … The patient was transported to the operating room.

3375. Assessing the Safety of Electronic Health Records: What Have We Learned? | PSNet
      psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned
      September 01, 2017 - The party in the best position to control the specific safety concern is generally in the best position … 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

3376. Strengthening the Business Case for Patient Safety | PSNet
      psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety
      May 01, 2013 - While Medicare's 2008 decision to penalize hospitals for poor quality and safety was one type of policy change … complications) did not accelerate the rate of change.( 17 ) On the other hand, an evaluation of a natural … desired behavior change. … to get the attention of the CEO and the board, and therefore much more likely to move the needle on patient … Do you think the state of the art is going there?

3377. Privacy or Safety? | PSNet
      psnet.ahrq.gov/web-mm/privacy-or-safety
      December 01, 2011 - 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

3378. In Conversation With… Ashish K. Jha, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-ashish-k-jha-md-mph
      May 01, 2013 - to get the attention of the CEO and the board, and therefore much more likely to move the needle on patient … Do you think the state of the art is going there? … While Medicare's 2008 decision to penalize hospitals for poor quality and safety was one type of policy change … complications) did not accelerate the rate of change.( 17 ) On the other hand, an evaluation of a natural … desired behavior change.

3379. In Conversation With… Jane Brice, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-jane-brice-md-mph
      May 01, 2019 - She also serves as the Program Director for the EMS Fellowship and was past-president of the National … Emergency physicians on the other side are champing at the bit to get their hands on the patient and … on the refrigerator and what's on the armband. … If they walk in the home, just start applying electricity to the chest, take the patient to the hospital … Teammate familiarity, teamwork, and risk of workplace injury in emergency medical services teams.

3380. Safety in the Prehospital Emergency Medical Services Setting | PSNet
      psnet.ahrq.gov/perspective/safety-prehospital-emergency-medical-services-setting
      May 01, 2019 - The dearth of data and information on patient safety in the EMS setting is linked to the absence of an … Teammate familiarity, teamwork, and risk of workplace injury in emergency medical services teams. … She also serves as the Program Director for the EMS Fellowship and was past-president of the National … on the refrigerator and what's on the armband. … If they walk in the home, just start applying electricity to the chest, take the patient to the hospital