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Showing results for "the change teams".

3481. Dying in the Hospital With Advanced Dementia | PSNet
      psnet.ahrq.gov/web-mm/dying-hospital-advanced-dementia
      November 01, 2016 - After communication with the family, the patient's care was transitioned to a focus on comfort and the … arrival at the patient's home, her resuscitation, intubation, and transfer to the hospital in the last … The family informed the PCP that the patient had died 2 months earlier. … In reality, the PCP had not been contacted, and the electronic health record system had not listed the … A mixed methods study examining teamwork shared mental models of interprofessional teams

3482. Missing Trauma | PSNet
      psnet.ahrq.gov/web-mm/missing-trauma
      March 03, 2011 - 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 of … ) from the injury or damage to the body. … In describing the mechanism of injury, he evoked the concept of energy exceeding the body's threshold … The fifth step is E for exposure and the environment.

3483. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33597/psn-pdf
      April 10, 2024 - 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. … (A PSNet primer summarized the prevalence and challenges that resulted in the enormous number of COVID … Over the past decade, post-acute patients represent an increasing proportion of the overall SNF patient … Winter of 2024 saw the biggest surge of COVID-19 cases since the end of the pandemic, despite several

3484. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49399/psn-pdf
      May 01, 2003 - https://psnet.ahrq.gov/web-mm/ectopic-or-not The Case The patient is a 24-year-old woman, gravida 4 … 15% change) hCG levels may be considered to have an ectopic pregnancy. … On the other hand, if the hCG levels do not fall, or instead continue to rise, the diagnosis of ectopic … In the featured case, it can be argued that the administration of methotrexate (and the exposure to … However, the level should be used during counseling of the patient.

3485. Milliliters vs. Milligrams | PSNet
      psnet.ahrq.gov/web-mm/milliliters-vs-milligrams
      September 01, 2004 - 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 multidose … ) to ensure it is the right drug, in the right dose, by the right route, for the right patient, at the … In this case, the pharmacist could have prevented the error by providing the initial dose in the ordered

3486. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33697/psn-pdf
      June 01, 2010 - practice of boarding admitted patients in the ED creates the greatest environmental contributor to … such as The Joint Commission and the Centers for Medicare & Medicaid Services have not developed or … Checklists and formalized handoffs may slow the flow and productivity of the ED and ultimately reduce … The effect of clinical experience on the error rate of emergency physicians. … The changing profile of patients who used emergency department services in the United States: 1996 to

3487. Amphotericin Toxicity | PSNet
      psnet.ahrq.gov/web-mm/amphotericin-toxicity
      April 01, 2014 - 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 floor … 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.

3488. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49605/psn-pdf
      June 01, 2010 - The criteria for severe preeclampsia are listed in the Table. … The required clinical and laboratory evaluations were not performed despite the fact that the nurse … the visit 2 days prior to the acute event, perhaps because they were afraid to question the knowledge … of the physician. … While much of the responsibility for decision-making rests with the physician, the nurses also demonstrated

3489. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50696/psn-pdf
      November 27, 2019 - Three patients were at the same hospital over the course of a few months for vascular access device … The day after the procedure, the patient was found at home in cardiac arrest and was pronounced dead … on and off in the past. … The actions performed by the vascular access staff were appropriate and the patient’s death could not … However, the acute onset of massive pulmonary embolism in the procedural setting is a reminder of the

3490. Abnormal Volunteer Results | PSNet
      psnet.ahrq.gov/web-mm/abnormal-volunteer-results
      July 18, 2016 - no symptoms), the patient wondered whether the delay in reporting the MRI findings to her led to growth … The determination of what is meant by "timely" should be a negotiation between the researcher and the … reviewing IRB in the context of the specific study details and will vary with the nature of the potential … finding and the immediacy of the threat to the participant. … The researcher has the responsibility to then carry through the methods exactly as prescribed in the

3491. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33820/psn-pdf
      December 01, 2016 - But the objective was the same. … Treating the symptoms doesn't get to the cause. … and know you followed the rule but put the patient at higher risk, or violate the rule for the benefit … a year of analyzing cases and implementing corrective actions using this method, there was a huge change … Tell the whole world, the press, the patients, and the community; then you just have to live by it.

3492. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49728/psn-pdf
      March 01, 2015 - While the medication mix-up was not identified by the dispensing pharmacist, the nurse responsible for … The Commentary With the ever-growing number of marketed drugs, the potential for look-alike and sound-alike … 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.

3493. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49662/psn-pdf
      August 01, 2012 - The primary team noted a remarkable similarity in appearance between the tube feeds and the stool. … During a tube check, it was discovered that the tip of the feeding tube was in the colon and not the … The second physician sterilely prepares the abdominal wall and anesthetizes the skin. … With the pull technique, the gastrostomy tube is affixed to the suture and "pulled" back through the … the PEG tube traverses the colon during insertion, presumably because the colon is between the stomach

3494. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49696/psn-pdf
      December 01, 2013 - The patient's pain was well controlled with the catheter, which was managed by the pain service at this … Later, when writing his note about the procedure, he glanced at the medication list and noticed the patient … 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 is rarely sufficient to drive behavior change … The rapidly evolving field of knowledge related to the use of TSOACs highlights the importance of developing

3495. Privacy Gone Awry | PSNet
      psnet.ahrq.gov/web-mm/privacy-gone-awry
      February 24, 2011 - Within the hour, the nurse heard loud inspiratory stridor coming from inside the curtain. … the patient. … almost sacred character of the relation of the physician has come to be lightly regarded, and the modern … have been detected before her stridor warned the nurse of a life-threatening change. … We too often neglect the rationale behind the rules; sometimes we focus on simply dotting the I's, crossing

3496. Glucose Roller Coaster | PSNet
      psnet.ahrq.gov/web-mm/glucose-roller-coaster
      February 02, 2022 - While in the step-down unit on the evening of admission, the patient had a routine phlebotomy sample … evening coverage during the busiest admitting time of the day. … Adding up all the "floating" (particularly since the implementation of the ACGME duty hours limitations … We are in the process of migrating the system to the web, creating a portal for nurses to access the … Effect of a change in house staff work schedule on resource utilization and patient care.

3497. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia | PSNet
      psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
      February 23, 2022 - 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 in … The intensivist should have also closed the loop by clarifying the recommendation with the nephrologist

3498. What Do We Know About Emergency Department Safety? | PSNet
      psnet.ahrq.gov/perspective/what-do-we-know-about-emergency-department-safety
      June 01, 2010 - The primary problem is the level of uncertainty. … performance of the physician about 90% of the time. … But at the end of the day, the clinical decision rule will outperform you, so why not use it? … PC: The major thing that we did was to change the nature of our M&M rounds. … We've developed a system here called casino shifts, where we actually change over at 3:00 in the morning

3499. EMS Perils from Hospital Overcrowding | PSNet
      psnet.ahrq.gov/web-mm/ems-perils-hospital-overcrowding
      November 25, 2020 - 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 … It is the opinion of the authors that the most critical safety issues identified in this case include … governing body of the hospital, not by “informal personnel appointments that could frequently change

3500. In Conversation with…Eric G. Poon, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-witheric-g-poon-md-mph
      September 01, 2008 - 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 … the nurse can be prompted to give the medications at the right time. … 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.