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Total Results: 3,566 records

Showing results for "the change teams".

3421. In Conversation With… Robert Hirschtick, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-robert-hirschtick-md
      January 01, 2018 - the billing rules are stupid, and chances are the neuro exam didn't change. … The interns and the residents came in the next day, and I told them about the patients. … the lungs and the heart and look at the neck veins. … the patient, it lived on in the EHR. … start using these toolkits and auditing features to help elucidate how best to educate, implement change

3422. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33846/psn-pdf
      November 01, 2017 - As in any major change management initiative, three major components determine the endeavor's success … that few apps address the needs of the patients who could benefit the most, and many of the apps are … By maintaining focus on the people as much as the processes, technology will boost the progression toward … Crossing the Quality Chasm: A New Health System for the 21st Century. … Patient-centered healthcare, social media and the internet: the perfect storm?

3423. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60168/psn-pdf
      March 25, 2020 - 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

3424. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49745/psn-pdf
      October 01, 2015 - First, the resident on the consulting ID team, unfamiliar with the different formulations of amphotericin … that would have notified the prescribing physician that the dose was out of the recommended range. … and did not recognize the toxic dose, either while compounding the medication or sending it to the … Finally, the nurse administering the infusion (given during shift change) did not recognize that the … The dosing error was not identified until the next morning.

3425. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49740/psn-pdf
      August 21, 2015 - 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

3426. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33797/psn-pdf
      January 01, 2016 - Those of us who have been trying for years to elevate the issue were particularly gratified to see the … The reasons for this are several. … the physician's mind. … To bolster measurement (9), patient safety teams can tap into a treasure trove of data from incident … of clinical practice amid the time pressures and the overwhelming electronic data.

3427. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49587/psn-pdf
      May 01, 2009 - The ED physician informed the paramedic team of the patient's death and reported that the patient had … Together, the paramedics and the ED physician examined the patient's clothing and discovered a drop … Further review of the admitting chest x-ray indicated the presence of a small caliber bullet in the … ) from the injury or damage to the body. … The fifth step is E for exposure and the environment.

3428. Spotlight (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.443_slideshow.ppt
      May 01, 2018 - Her colleague was covering the electronic inbox (the portal within the electronic health record in which … The rheumatologist happened to have two patients with the same last name, and both had GCA. … The rheumatologist quickly called the patient for a follow-up appointment and realized that the elevated … In the setting of the ongoing headache and joint pain with a persistently elevated CRP, the rheumatologist … marked the elevated CRP as reviewed, thus hiding the result in the inbasket of the returning rheumatologist

3429. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33727/psn-pdf
      March 01, 2012 - system, there seems to have been little change that has addressed all sides of the problem. … that causes physicians to worry about the financial consequences, the psychological effects of the … The error is intercepted by the hospital pharmacist before the medication is scheduled to be administered … and the order canceled by the physician. … However, because the pharmacist was not able to communicate this to the nurse in time, the medication

3430. In Conversation With… David Blumenthal, MD, MPP | PSNet
      psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp
      July 01, 2012 - the top. … How do you think that will change the nature of doctoring and nursing, the way we need to train people … Therefore, the rate of change will continue to be very fast. … Those sources will change over time, and it's the generic skill with knowledge management that we need … Medications and treatments change over the course of hospitalization.

3431. In Conversation With… Mark L. Graber, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-mark-l-graber-md
      January 01, 2016 - We get it right more than 90% of the time, and that's really amazing given the complexity of the task … The report involved the work of some 30 individuals over a period of 18 months, with the final report … Another major advance in the report is the framework that it presents about the diagnostic process. … The second is the oral exam, which I think is still done in the UK but is long gone in medicine in the … To bolster measurement ( 9 ), patient safety teams can tap into a treasure trove of data from incident

3432. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49522/psn-pdf
      November 01, 2006 - The next day, the patient reported that her pain was worse, and the team noted an 8-centimeter hematoma … This can occur when the association between the process measure and the desired outcome is weak, or … when 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 … must recognize that unintended consequences are bound to occur following any effort to implement change

3433. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49852/psn-pdf
      February 01, 2019 - 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.

3434. Bad Writing, Wrong Medication | PSNet
      psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
      March 01, 2015 - The patient delivered the prescription to the clinic pharmacy, and it was filled. … "( 2 ) The relationship between the two is illustrated in the Figure . … Case & Commentary: Part 2 Based upon the altered appearance of the tablets, both the patient and the … the EMR, checking with the patient, or telephoning the prescriber's office. … (iii) patient empowerment to question the change in prescription in a timely fashion.

3435. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts. | PSNet
      psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
      October 31, 2023 - the potential danger from escalating doses of these medications over several days, until the patient … interruptive (where the alert appears on the screen and the clinician must act on the alert to complete … the workflow). … Failure to adjust the dose in the setting of renal insufficiency may increase the risk of encephalopathy … In the case of alerts for patients withCKD, instead of using the problem list, the EHR could use the

3436. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/843234/psn-pdf
      January 01, 2013 - Describe the signs and symptoms of gabapentin toxicity Recognize the need for careful dose adjustment … Many of the most used medications to treat pain are cleared by the kidney, and thus must be carefully … interruptive (where the alert appears on the screen and the clinician must act on the alert to complete … the workflow). … In the case of alerts for patients withCKD, instead of using the problem list, the EHR could use the

3437. Can Research Help Us Improve the Medical Liability System? | PSNet
      psnet.ahrq.gov/perspective/can-research-help-us-improve-medical-liability-system
      March 01, 2012 - system, there seems to have been little change that has addressed all sides of the problem. … the jury was filing out of the box and the lady who sued leaned around the podium and said to the surgeon … Thank you very much, but we didn't ask for any opinions about how we could change our clinical care, … First with the culture change: peer review, for instance, has traditionally meant that we wait until … If we change the feel of it from punitive to progressive, we won't feel so badly and we won't work so

3438. In Conversation With… Richard C. Boothman, JD | PSNet
      psnet.ahrq.gov/perspective/conversation-richard-c-boothman-jd
      March 01, 2012 - the jury was filing out of the box and the lady who sued leaned around the podium and said to the surgeon … Thank you very much, but we didn't ask for any opinions about how we could change our clinical care, … First with the culture change: peer review, for instance, has traditionally meant that we wait until … If we change the feel of it from punitive to progressive, we won't feel so badly and we won't work so … system, there seems to have been little change that has addressed all sides of the problem.

3439. Spotlight
      psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
      January 01, 2025 - The accuracy of CT for diagnosing the cause of abdominal pain depends on the location of pain and the … Background – Imaging (5) In this case, because the diagnosis was not clear from the ultrasound, the next … Unfortunately, the clinician failed to recognize that the results of the ultrasound did not explain the … of traveling from the ED to the radiology suite. … The value of C-reactive protein and lactate in the acute abdomen in the emergency department. 

3440. Blind Spot | PSNet
      psnet.ahrq.gov/web-mm/blind-spot
      July 30, 2020 - the optic nerve and retinal vessels enter the globe. … the globe. … sudden blockage of the blood supply to the retina, often referred to as a “stroke” of the eye. … Mayfield pins are an alternative to the horseshoe headrest in the prone position when the eyes cannot … The horseshoe headrest’s design puts the majority of the pressure of the face on the outer rim without