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Showing results for "the change teams".

3461. Coronavirus Disease 2019 (COVID-19) and Diagnostic Error | PSNet
      psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error
      July 30, 2020 - from other federal agencies and the peer-reviewed literature are listed at the end. … The emergence of the Delta variant, the Omicron variant, and other variants of concern (VOCs) has resulted … The White House. … Laboratory diagnosis of emerging human coronavirus infections - the state of the art. … The effect of spectrum of disease on the performance of diagnostic tests.

3462. Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice | PSNet
      psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-practice
      January 01, 2016 - To bolster measurement ( 9 ), patient safety teams can tap into a treasure trove of data from incident … 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

3463. Patient Safety in the Physician Office Setting | PSNet
      psnet.ahrq.gov/perspective/patient-safety-physician-office-setting
      November 04, 2015 - in the United States is provided in the outpatient setting. … from the literature to improve the medication prescription process in the office setting include the … The Testing Process According to data from the National Ambulatory Medical Care Survey, the average … tests, tracking the results, responding to and documenting the response, notifying the patient, and … The response to the report (normal, abnormal) also needs to be noted by the physician, and empowering

3464. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49641/psn-pdf
      November 01, 2011 - Analysis of the case revealed that the oncology department lacked a standard practice to check hepatitis … Moreover, the admitting team erred by not considering the possibility of hepatitis as the cause of the … Rarely, hepatitis may be caused by tumor obstruction of the hepatic veins producing the Budd-Chiari … In this patient, the cause of the initial elevation in transaminases was not completely explored. … However, a major concern with its prolonged use is the emergence of resistance mutations in the YMDD

3465. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50842/psn-pdf
      January 29, 2020 - Upon receiving all the CT results, the ED team recognized that the results were not consistent with … in the post-anesthesia care unit (PACU), and was admitted to the pediatric unit late in the day. … The next day, the night shift RN discovered the child had another patient’s identification (ID) band … The ID band belonged to an 8-month-old baby boy who also had been seen in the ED the previous https: … the wrong family and delivered the devastating news to them.1 The mistake, although corrected only twenty

3466. Procedural Mishap: Learning Curve? | PSNet
      psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
      April 28, 2021 - needle or the first trocar.( 6 ) The most commonly injured major vessels are the distal aorta and the … In the anesthetized abdomen, the take off of the RCIA lies only 3-4 cm directly below the umbilicus. … up” the abdominal wall and to hold the skin tight at the umbilicus so that when the needle is inserted … The severity of the injury in this case suggests it was caused by the trocar. … to question both the design and the reliability of the devices used.

3467. Building a Safety Program Using Principles of Resilience Engineering | PSNet
      psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
      October 23, 2013 - 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 system, as the push for efficiency forces it to function at capacity. … Most of the time, the OR staff manage such trade-offs individually and as a group without ill effects … The following are some of the key challenges that influence the implementation of a resilience engineering-based

3468. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49625/psn-pdf
      May 01, 2011 - 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 … There is no agreement, for example, on the definition of the term "error," even at the most basic level … the patient was moved from the OR.

3469. Patient Safety in Primary Care | PSNet
      psnet.ahrq.gov/perspective/patient-safety-primary-care
      January 31, 2020 - challenges, including the types of error and the wide variety of patient populations that may be affected … that have contributed to the opioid epidemic and the rise of antibiotic resistant infections. [4 … when patients are hospitalized to ensure primary care clinicians are able to communicate with hospital teams … Explicit agreements on the roles and responsibilities surrounding patient care between the primary care … and the patient.

3470. The Role of Bar Coding and Smart Pumps in Safety | PSNet
      psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety
      September 01, 2008 - of medication safety: getting the right dose of the right drug to the right patient using the right … the correct medication at the correct time to the correct patient. … Then the pharmacy needs to approve the medications and set the right schedules electronically for the … One of the things that I may suggest would be for each organization to consider the capacity for change … Although I'm hopeful that will probably change.

3471. In Conversation With... Elsabeth Kalenderian, DDS, MPH, PhD and Muhammad F. Walji, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-elsabeth-kalenderian-dds-mph-phd-and-muhammad-f-walji-phd
      December 22, 2020 - The good thing about large academic institutions and many of the 50-60 dental schools in the US is that … the errors. … the incidence of the AE's. … The biggest AE is pain and while pain may be normal, we need to change the perspective that focuses on … The other side of the equation is that you need to have calibrated faculty that talk the same language

3472. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837958/psn-pdf
      December 01, 2021 - The clinician suspected septic arthritis and sent the patient to the Emergency Department (ED) via ambulance … However, the ED staff were not informed of the incoming patient or the orthopedic surgeon’s plan for … When the patient arrived at 19:40, the ED was severely impacted with a high volume of patients in the … The patient stayed in the ED hallway on “wall time” under the care of the Emergency Medical Services … governing body of the hospital, not by “informal personnel appointments that could frequently change

3473. Adverse Events in Dentistry | PSNet
      psnet.ahrq.gov/perspective/adverse-events-dentistry
      December 22, 2020 - The good thing about large academic institutions and many of the 50-60 dental schools in the US is that … the errors. … the incidence of the AE's. … The biggest AE is pain and while pain may be normal, we need to change the perspective that focuses on … The other side of the equation is that you need to have calibrated faculty that talk the same language

3474. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33855/psn-pdf
      April 01, 2018 - dietitian, the nurse, the doctor, and the work clerk, etc." … They each went down the line. The patient was an actor. … in the old days, it would have been in the hospital. … What have we learned from that measure that is generalizable to our efforts to change the payment and … measurement for quality improvement from reasonable measurement for accountability and incentivizing change

3475. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33862/psn-pdf
      July 01, 2018 - Nundy is the Director of the nonprofit organization called the Human Diagnosis Project, a unique effort … Is it the Isabels of the world? Or the Watsons of the world? … The second is the decision aids. … and the needs of the underserved. … late and have someone with complex social issues, it reminds me that I have to go back on Monday and change

3476. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61083/psn-pdf
      October 28, 2020 - We are in the eighth year now, and the second phase of the work. … If you don’t put value in the CNA the project is dead in the water. … 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

3477. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72613/psn-pdf
      December 22, 2020 - The good thing about large academic institutions and many of the 50-60 dental schools in the US is that … We focused on just measuring the harm to the patient as the first step and not worrying about who’s … the incidence of the AE's. … The biggest AE is pain and while pain may be normal, we need to change the perspective that focuses … from the IOM.

3478. The Lost Start Date: an Unknown Risk of E-prescribing | PSNet
      psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
      December 02, 2020 - 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 … The patient safety committee at the hospital performed a full review of the case.

3479. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy | PSNet
      psnet.ahrq.gov/web-mm/risks-absent-interoperability-medication-induced-hemolysis-patient-known-allergy
      April 08, 2019 - Based on the clinical presentation, the hemolysis was presumed to have been caused by a reaction to the … The first step at the receiving hospital (Hospital Y) is to confirm that the document refers to the same … The ATM and the bank are interoperable. Are the two hospitals? Not yet. … above—that is, with the push of a button, after the accuracy of the exchange is verified, the key and … The people need to accept change and embrace the tools—even if they remain imperfect.

3480. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_delayed_symptomatic_subdural_hematoma_slides.pptx
      January 01, 2024 - He was taken urgently to the operating room, where craniotomy was performed and the hematoma was evacuated … by the Canadian CT Head Rule (CCHR), which recommends head CT if any of the following signs are present … dura mater of the brain and are more likely to be seen in the elderly population, given the presence … If the expanding mass lesion is left untreated, the patient will eventually develop focal neurological … Validation of the sensitivity of the National Emergency X-Radiography Utilization Study (NEXUS) Head