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Total Results: 3,566 records

Showing results for "the change teams".

3441. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50611/psn-pdf
      October 30, 2019 - The discharging nurse reviewed the full medication list (13 medications) with the patient and his wife … The prescriptions were filled by the pharmacy. … Ten days later, the patient's wife returned to the pharmacy requesting a refill of the rivaroxaban 15 … On re-reviewing the medications, the wife explained the patient had been taking both prescriptions at … at the hospital performed a full review of the case.

3442. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49744/psn-pdf
      October 01, 2015 - The first step at the receiving hospital (Hospital Y) is to confirm that the document refers to the … The ATM and the bank are interoperable. Are the two hospitals? Not yet. … The barriers to the rapid and accurate transmission of information are many and beyond the scope of … above—that is, with the push of a button, after the accuracy of the exchange is verified, the key https … The people need to accept change and embrace the tools—even if they remain imperfect.

3443. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61082/psn-pdf
      July 23, 2020 - far-reaching consequences on how the healthcare community approaches the delivery of care. … safety of both the patient and the healthcare workforce. … more permanent structural and programmatic change is needed. … The Washington Post. … The Buffalo News.

3444. Flying Object Hits MRI | PSNet
      psnet.ahrq.gov/web-mm/flying-object-hits-mri
      September 01, 2005 - When the scan was completed and the patient was to be wheeled out from inside the scanner, the anesthesiologist … brought the pump to the foot of the bed to secure it to a bracket there. … The impact damaged the pump, but the child was unharmed. … after the magnet causes the pump to rotate in the opposite direction). … April 19, 2013 Findings of the first consensus conference on medical emergency teams.

3445. Is It Safe to Be Direct? | PSNet
      psnet.ahrq.gov/web-mm/it-safe-be-direct
      September 30, 2015 - the hospitalist on call to report the clinical history. … The case prompted the hospital to consider the safety of admitting patients directly from outpatient … The Commentary For the patient, a direct admission to the hospital may seem attractive compared to … bed from the admitting office, (iii) the bed assignment clerk alerts the hospitalist about the pending … on the report to the admitting hospitalist once the patient arrives on the floor.

3446. Chemotherapy Administration Safety Standards | PSNet
      psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
      March 30, 2016 - entered the order into the computer. … Inadvertently, while transcribing the order, the pharmacist switched the duration of therapy for the … The patient received the correct doses on the first day (since the transposition didn't affect this); … When the dose reached the bedside, the patient's nurse was in a hurry and bypassed the double-check policy … additional medications and/or cycles of therapy) and unintentional propagation (i.e., providers make a change

3447. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50843/psn-pdf
      January 29, 2020 - The nephrologist briefly reviewed the laboratory results and asked the intensivist to administer hypertonic … When the nephrologist came to the ICU about two hours later, the patient's confusion had not improved … to mitigate the effect of the rapid sodium correction. … Unfortunately, the free-text comment was missed both by the pharmacist and the ICU nurse, resulting … The intensivist should have also closed the loop by clarifying the recommendation with the nephrologist

3448. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49726/psn-pdf
      March 01, 2015 - Describe the incidence of wrong-site surgery, and the impact the Universal Protocol has had on the prevention … The day following the surgery, the pathologist contacted the surgeon to report no evidence of cancer. … at the time of the surgery. … to the discretion of the surgeon. … For example, a change in hospital policy requiring imaging to be present in the operating suite prior

3449. Hazards of Loading Doses | PSNet
      psnet.ahrq.gov/web-mm/hazards-loading-doses
      December 01, 2003 - As part of the initial ED patient evaluation, the neurology fellow (seeing the patient because of her … Unfortunately, the physician failed to order that the dose be switched back to the appropriate maintenance … dose of once daily after the loading was completed, so the patient continued to receive IV phenytoin … Investigation of the event revealed that the admitting medicine physician did notice the unusually high … transfer of care from the emergency department to the intensive care unit.

3450. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49560/psn-pdf
      April 01, 2008 - preferences with the patient and the family. … he had been taken to the OR for the AAA repair. … The family agreed with the patient's choice. … Ultimately, the internist consulted with the hospital ethicist, who convinced the surgeon to honor the … Indeed, the patient signed a DNR order in the nursing home, and the family agreed with the patient's

3451. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49616/psn-pdf
      December 01, 2010 - The pharmacist labeled the vial, instructing the nurse regarding the necessary volume (mL) to be drawn … After questioning the nurse, the pharmacist determined that the patient was given the entire vial (20 … The second error in this case occurred when the nurse administered the entire contents of the 20-mg … ") to ensure it is the right drug, in the right dose, by the right route, for the right patient, at … In this case, the pharmacist could have prevented the error by providing the initial dose in the ordered

3452. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49655/psn-pdf
      June 01, 2012 - in the right femoral vein. … The unused clotted AV graft in the left arm remained in place, and the patient was transferred to a … The patient would ask the nurses to "push the hydromorphone fast" and flush after the medication (saying … The appropriate management of chronic pain in kidney failure and the evidence to support the use of … approach will be carried over to hospital admissions (excepting indications necessitating a short-term change

3453. Timely diagnosis of esophageal perforation | PSNet
      psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation
      September 27, 2023 - In the absence of such historical characteristics, physicians should strongly consider the diagnosis … have increased substantially with the finding of fungal contamination of the pleural space.   … appearance of the pleural fluid—frequently help point physicians to the correct diagnosis.  … However, control of the source of sepsis is critical, and the physicians—including the surgeon who performed … Did the intensive care physicians assume that the surgeon who performed the initial decortication must

3454. Rapid Mis-St(r)ep | PSNet
      psnet.ahrq.gov/web-mm/rapid-mis-strep
      February 01, 2004 - The remainder of the examination, including the abdominal examination, was unremarkable. … Concerned, the father took the child to the nearest emergency department (ED). … The ED physician repeated the RADT. … Essentially no change in management has occurred! … in the Young, the American Heart Association.

3455. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.311_slideshow.ppt
      December 01, 2013 - the pain service at this hospital. … or other traditional anticoagulants, but he did not review the rest of the list. … procedure, the fellow glanced at the medication list and noticed the patient was on rivaroxaban. … The surgical team and pain service disclosed the error to the patient and monitored her very closely … clinicians is certainly a component of effective interventions, but rarely sufficient to drive behavior change

3456. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33600/psn-pdf
      June 16, 2024 - Background The History of the Patient Safety Movement The concept that patients could be harmed while … The term iatrogenesis—still used today to indicate harm experienced by patients at the hands of the … Reason's work led to the development of the systems approach, which takes the view that most errors … change the underlying systems of care in order to reduce the occurrence of errors or minimize their … Another challenge for the field is the need to improve safety across the continuum of care.

3457. Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis | PSNet
      psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
      March 09, 2022 - Immediately after the operation, the surgeon informed the patient and instructed him to lie flat on his … Ideally, the patch/graft material should restore the continuity of the dura mater, minimize CSF leak, … It is thought that the blood forms a clot over the dural tear, allowing healing of the dura. … the dura mater does not come between the footplate of the rongeur and bone. … March 9, 2022 Culture change in infection control: applying psychological principles

3458. Adolescent Diabetes: A Routine Visit? | PSNet
      psnet.ahrq.gov/web-mm/adolescent-diabetes-routine-visit
      November 18, 2016 - The regimen prescribed for the patient in the case presentation is both unusual and unclear. … The rest of the review of systems was unremarkable. … The rest of the examination was unremarkable. … The following day, the pediatrician's office received a call from an obstetrician reporting that the … On the first visit and periodically thereafter, the clinician should discuss confidentiality with the

3459. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33688/psn-pdf
      October 01, 2009 - The head of the emergency department filed an affidavit as part of the suit, citing specific cases in … The first was that two women died over the summer. … the monitors. … That's one of the areas where I think the L.A. … the L.A.

3460. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49657/psn-pdf
      July 01, 2012 - the procedure. … ultrasound to identify the fluid to perform the paracentesis safely. … The resident felt comfortable proceeding with the procedure with the intern, who had never done one … The interventional radiologist was unable to embolize the vessel, so the patient underwent emergent … The SBML minimum passing score is set at a high level by experts in the field that understand the implications