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Total Results: 3,566 records

Showing results for "the change teams".

3501. What Was in Those Platelets? | PSNet
      psnet.ahrq.gov/web-mm/what-was-those-platelets
      August 28, 2024 - Given the similarity in clinical course, the hospital investigated the two cases. … The bacterium was never cultured from the blood of the 76-year-old man, but he remained febrile in the … , in concert with the clinical service, organizes the report for submission to the FDA. … or asymptomatic with a positive blood culture or leukocytosis 3/6.5% A transient change … in vital signs resolved within 24 hours with minimal intervention 3/6.5% A change

3502. In Conversation With… Shantanu Nundy, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-shantanu-nundy-md
      February 26, 2025 - Those are the secret sauce of how we've built the engagement around the system. … 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

3503. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49566/psn-pdf
      July 01, 2008 - Given the similarity in clinical course, the hospital investigated the two cases. … The bacterium was never cultured from the blood of the 76-year-old man, but he remained febrile in the … , in concert with the clinical service, organizes the report for submission to the FDA. … temperature increase) or asymptomatic with a positive blood culture or leukocytosis 3/6.5% A transient change … pubmed/7974703 http://www.fda.gov/cber/gdlns/bldfatal.htm https://psnet.ahrq.gov//#references 3/6.5% A change

3504. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867022/psn-pdf
      October 30, 2024 - The Case A man in his mid-50’s presented to the hospital for a persistent headache after a sledding … for brain injury often includes CT of the head, especially given the ubiquitous presence of CT scanners … guided by the Canadian CT Head Rule (CCHR), which recommends head CT if any of the following signs are … dura mater of the brain and are more likely to be seen in the elderly population, given the presence … Critique of Patient Care The acute management of this patient at the time of his first presentation

3505. Emerging Safety Issues in Artificial Intelligence | PSNet
      psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence
      February 20, 2019 - When the patient is not adequately represented by the data that the machine learning system was trained … on, the accuracy of the system will be compromised. … However, the severity of these issues depends critically on the AI application. … to the unaided clinician. … The comparison between the clinician supported by machine learning versus the clinician without machine

3506. DRESSed for Failure | PSNet
      psnet.ahrq.gov/web-mm/dressed-failure
      September 01, 2011 - The Case A 60-year-old woman who uses a wheelchair presented to the emergency department (ED) with … One week later, the patient returned to the ED critically ill with hypotension, altered mental status … The medical center recently transitioned to a new EHR, and the institution made a deliberate decision … over from the old system. … However, despite a few ambulatory visits for this patient since transition to the new EHR, the allergy

3507. Wrong Turn through Colon: Misplaced PEG | PSNet
      psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
      May 01, 2017 - 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 … when the PEG tube traverses the colon during insertion, presumably because the colon is between the stomach

3508. Patient Identification Errors: A Systems Challenge | PSNet
      psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
      February 23, 2011 - Upon receiving all the CT results, the ED team recognized that the results were not consistent with physical … 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 day but … The Commentary By Lamia S.

3509. Liver Failure After Chemotherapy: Did We Forget Something? | PSNet
      psnet.ahrq.gov/web-mm/liver-failure-after-chemotherapy-did-we-forget-something
      May 01, 2019 - 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 … 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 … region of the HBV DNA polymerase.

3510. Acute Respiratory Arrest in Pregnancy | PSNet
      psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
      August 15, 2018 - 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 suspected … Moreover, the nurses failed to communicate to the physician their concern about preeclampsia during the … the physician. … While much of the responsibility for decision-making rests with the physician, the nurses also demonstrated

3511. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49848/psn-pdf
      January 01, 2019 - On arrival at the patient's cubicle, the anesthesiologist found the curtain was drawn around the patient's … as the posterior tongue mass, the size of a small lemon, obscured the view of the larynx. … , the perceived increase in time that it would take to prepare the patient and the equipment for the … The patient safety benefit of performing the evaluation prior to the day of surgery has resulted in the … The ability to review the CT scan may have influenced the anesthetic plan and potentially avoided the

3512. Chemotherapy Extravasation | PSNet
      psnet.ahrq.gov/web-mm/chemotherapy-extravasation
      September 24, 2010 - Upon closer examination, the nurse noted that the chemotherapy had infused outside of the vein (extravasated … The nurse removed the IV catheter and placed an ice pack on the site. … Eventually, the IV site was bandaged and the patient was sent home to return later in the week. … Extravasation of the medication into the skin is one of the most dreaded complications that can occur … In the case above, the IV device was inserted with some difficulty, and the nurse proceeded with vesicant

3513. Infused, Not Ingested | PSNet
      psnet.ahrq.gov/web-mm/infused-not-ingested
      February 01, 2017 - When the patient arrived for the study, the radiology technician asked the nurse whether the patient … contrast” in the trash after the nurse departed from the radiology suite. … The physician caring for the patient did not inform the family of the error until the following morning … cause of the entire event or, at the least, the nurse’s initial response to the error. … Refused Medication Error February 1, 2017 Leading successful rapid response teams

3514. Shortcuts to Acetaminophen-induced Liver Failure | PSNet
      psnet.ahrq.gov/web-mm/shortcuts-acetaminophen-induced-liver-failure
      July 01, 2017 - The Case An 18-year-old woman, 27 weeks pregnant, presented to the emergency department (ED) after … or surgical risks need to be balanced against not just the risk of the treatment to the fetus, but also … against the risks to the mother and fetus of nonintervention or nondiagnosis. … death of the mother would also result in loss of the fetus. … of the medications and procedures, but also the risk of failure to treat or diagnose.

3515. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33864/psn-pdf
      January 01, 2019 - The use of these methodologies depends upon the end goal. … As indicated by the name, the interactions that take place are virtual in that the learner interacts … With the integration of haptic interfaces, some VR simulators now have the capacity to promote the acquisition … each year in the US.(11) A systematic review of 21 studies over 15 years tested the impact of the use … education: do conferences, workshops, rounds, and other traditional continuing education activities change

3516. Ectopic or Not? | PSNet
      psnet.ahrq.gov/web-mm/ectopic-or-not
      March 27, 2024 - The patient was discharged home the next day and her hCG showed an appropriate decline. … 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 the … However, the level should be used during counseling of the patient.

3517. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49783/psn-pdf
      February 01, 2017 - to the MRI. … On that study, the radiologist noted that the subdural hematoma had enlarged and the midline shift had … of this order at the time of the review. … unrealistic to expect busy clinicians to mechanistically review all their medication orders, and then to change … the EHR.

3518. The Wrong Channel | PSNet
      psnet.ahrq.gov/web-mm/wrong-channel
      February 01, 2003 - The nurse increased the pump rate to 500 mL/hour, but within 20 minutes, the patient reported feeling … While checking the pump, the nurse realized that she had inadvertently increased the magnesium sulfate … The Commentary We have all seen “someone else” turn on the wrong burner on the stove and burn themselves … Luckily, these mix-ups, and the steps taken to prevent them, can help point the way to preventing the … April 19, 2013 Findings of the first consensus conference on medical emergency teams.

3519. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33605/psn-pdf
      March 12, 2021 - 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. … readable, the medication is not labeled or not in the system, or the scanning equipment malfunctions … the EHR. … Based on this trigger, the pump can stop the PCA infusion, which may, in turn, reduce the possibility

3520. The Case for Patient Flow Management | PSNet
      psnet.ahrq.gov/web-mm/case-patient-flow-management
      February 23, 2019 - The patient's daughter notified the resident that the patient had died after driving her car into a tree … While there was no way to be certain, a review of the case by the involved clinicians raised the possibility … Given the unknown number of unscheduled patients coming to the office on a particular day, the schedule … The right solution will be to find the least busy part of the day, when scheduled patient demand is lowest … February 23, 2019 Rethinking rapid response teams.