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Total Results: 3,566 records

Showing results for "the change teams".

3401. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49697/psn-pdf
      December 01, 2013 - Once in the operating room, the resident placed an arterial line in the patient's left arm under local … Because the patient was unable to tolerate the facemask oxygen (due to claustrophobia), the attending … The anesthesiologist then injected 2 mg of midazolam to sedate the patient. … The logbook on the anesthesia machine showed that the machine had been checked that morning, but the … But, the distraction of the unexpected change of patient responsiveness would have led the anesthesiologist

3402. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49387/psn-pdf
      February 01, 2003 - 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 … in the medication room, in the pharmacy, on the door to the patients' rooms or other places relevant … So, the brain tumor's on the left, right?

3403. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression | PSNet
      psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
      May 26, 2021 - The patient was transferred from the PACU to the surgical floor at 20:00 where supplemental oxygen was … with 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

3404. Errors and Near Misses: What Health Care Could Learn From Aviation | PSNet
      psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
      September 01, 2006 - But change may be coming: in 2016 the English National Health Service has launched a new Healthcare Safety … the past and improve the future. … JB: Well, the biggest thing was the culture. … My goal when I came here was to change the culture. … That's a big sea change for people to think about, but it makes sense.

3405. Suicide Prevention | PSNet
      psnet.ahrq.gov/perspective/suicide-prevention
      March 24, 2025 - the majority of people who die by suicide have interacted with the healthcare system in the weeks or … response should be tailored both to the healthcare setting and to the severity of the risk. … Everyone uses the same type of device; the numbers mean the same thing. … to stratify, as I mentioned earlier, to match the intensity of the intervention to the severity of the … ’s expansion of the Sentinel Event window after discharge, then health systems might change their practices

3406. In Conversation with Edwin Boudreaux about Suicide Prevention | PSNet
      psnet.ahrq.gov/perspective/conversation-edwin-boudreaux-about-suicide-prevention
      March 25, 2025 - Everyone uses the same type of device; the numbers mean the same thing. … The age of the patient population is also important. … to stratify, as I mentioned earlier, to match the intensity of the intervention to the severity of the … In the outpatient setting, the process is similar. … ’s expansion of the Sentinel Event window after discharge, then health systems might change their practices

3407. Spotlight: Mistaken Attribution, Diagnostic Misstep | PSNet
      psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
      July 01, 2011 - 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

3408. In Conversation with...David Marx, JD | PSNet
      psnet.ahrq.gov/perspective/conversation-withdavid-marx-jd
      October 01, 2007 - Nobody is suggesting that the surgeon is accountable for the harm to the patient. … the behavior of others, and the culture at the point of care, or team culture. … 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.

3409. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33750/psn-pdf
      May 01, 2013 - The most important is that our community has gone from looking at errors as purely the fault of the … To the degree that you think they relate to incentives and the lack of a business case, what does the … Public reporting reaches the level of the chief quality officer or the medical director who finds it … to get the attention of the CEO and the board, and therefore much more likely to move the needle on … Do you think the state of the art is going there?

3410. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49714/psn-pdf
      August 21, 2014 - Describe the main challenges in the diagnosis of necrotizing fasciitis. … Understanding the pathophysiology enables the clinician to appreciate the insidious progression of NF … Pain out of proportion to the skin manifestations is the most consistent feature noted at the time of … Use of clinical pathways (34) and involvement of multidisciplinary teams with updates and education … Surgical Memoirs of the War of the Rebellion.

3411. Pitfalls in Diagnosing Necrotizing Fasciitis | PSNet
      psnet.ahrq.gov/web-mm/pitfalls-diagnosing-necrotizing-fasciitis
      March 24, 2021 - Understanding the pathophysiology enables the clinician to appreciate the insidious progression of NF … help the clinician make the diagnosis. … Pain out of proportion to the skin manifestations is the most consistent feature noted at the time of … Use of clinical pathways ( 34 ) and involvement of multidisciplinary teams with updates and education … Surgical Memoirs of the War of the Rebellion.

3412. In Conversation With...Donald A. Norman, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd
      November 01, 2006 - effects of the drugs on the patient. … Then maybe we could change the situation. … They do not simplify your task, they change your task. So instead of doing x, you're now doing y. … The technology changes the nature of the job. … How about if the pharmacist had demonstrated the new nasal medication delivery to the patient, but the

3413. In Conversation With… David Blumenthal, MD, MPP | PSNet
      psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp-0
      March 27, 2024 - to change their behavior. … your thoughts on have they surprised you, have they changed things, or how you think they're going to change … The Silicon Valley interest is they are the extractors, the refiners, and the marketers, and they're … in the paper world in order to create confidence that the government would supervise the privacy of the … , and the people who understand the code.

3414. Silent Pain in the Neck | PSNet
      psnet.ahrq.gov/web-mm/silent-pain-neck
      August 19, 2020 - 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

3415. Medication Mix-Up: From Bad to Worse | PSNet
      psnet.ahrq.gov/web-mm/medication-mix-bad-worse
      March 01, 2018 - While the medication mix-up was not identified by the dispensing pharmacist, the nurse responsible for … While comparing the medication order to the delivered medication, the nurse discovered that the incorrect … likely contributed to the selection error during the dispensing process in the pharmacy. … the list with the dispensed medications. … drug name confusion errors.( 6 ) In such alerts, the CPOE notifies the clinician that the patient's

3416. Long-term Care and Patient Safety | PSNet
      psnet.ahrq.gov/primer/long-term-care-and-patient-safety
      February 24, 2022 - One of the reasons for the lower numbers is due to the almost 200,000 people who died of COVID-19 in … nursing homes during the pandemic. … The facilities may be freestanding or attached to an acute hospital, and they are subject to the same … Winter of 2024 saw the biggest surge of COVID-19 cases since the end of the pandemic, despite several … Adults Residing in Nursing Homes February 24, 2022 Organizational readiness to change

3417. Medication Administration Errors | PSNet
      psnet.ahrq.gov/primer/medication-administration-errors
      December 15, 2024 - If the prescription didn’t change, the tablet color shouldn’t either. … right dose of the right medication to the right patient at the right time. … , the medication is not labeled or not in the system, or the scanning equipment malfunctions. … the EHR. … Editor's Picks An analysis of incident reports related to electronic medication management: how they change

3418. Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit | PSNet
      psnet.ahrq.gov/perspective/quality-and-safety-challenges-critical-care-preventing-and-treating-delirium-intensive
      December 01, 2012 - Nurse-led change: a statewide multidisciplinary collaboration targeting intensive care unit delirium. … impossible to say if it's an acute change or not. … They can repeat after you or say the days of the week or the months of the year backwards. … They may be having an MI and just present with the mental status change. … the breathing treatment, the IV change, the lab, blood draws, the medications, the vitals, the O2 sat—everything

3419. In Conversation With... Charles A Crecelius, MD, PhD, CMD and Lori L Popejoy, PhD, RN, FAAN | PSNet
      psnet.ahrq.gov/perspective/conversation-charles-crecelius-md-phd-cmd-and-lori-l-popejoy-phd-rn-faan
      October 28, 2020 - We are in the eighth year now, and the second phase of the work. … KH : Was that home acting like an essentially short-stay or a skilled nursing facility and they just change … you using the work and the lessons from the initiative in your approach to the pandemic? … CC: With the APRN presence, principles of infection control, early identification of change in condition … more permanent structural and programmatic change is needed.

3420. Long-Term Care and the Response to COVID-19 | PSNet
      psnet.ahrq.gov/perspective/long-term-care-and-response-covid-19
      October 28, 2020 - more permanent structural and programmatic change is needed. … We are in the eighth year now, and the second phase of the work. … KH : Was that home acting like an essentially short-stay or a skilled nursing facility and they just change … you using the work and the lessons from the initiative in your approach to the pandemic? … CC: With the APRN presence, principles of infection control, early identification of change in condition