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Total Results: 3,566 records

Showing results for "the change teams".

3521. The Wrongful Resuscitation | PSNet
      psnet.ahrq.gov/web-mm/wrongful-resuscitation
      October 12, 2012 - 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

3522. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough | PSNet
      psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
      September 01, 2003 - The physician order was to remove the pack the next day when the Foley catheter was removed.  … The next day, the ward nurse read the physician’s order to remove the Foley and the packing. … The nurse removed the Foley catheter and the 4x4’s, the Kerlix™ fluff and the peri-pad, assuming this … The physician came by to see the patient just before discharge and asked the patient, using the patient … the patient has left the operating room and the PACU.

3523. Mixup Beyond the Medication Label | PSNet
      psnet.ahrq.gov/web-mm/mixup-beyond-medication-label
      June 01, 2014 - Approximately 2 weeks after the second discharge, the patient experienced another severe hypoglycemic … This check revealed the only clue to the dispensing error committed by the community pharmacy. … then scanning the barcode of the product being dispensed to ensure correct product selection. … Provide patient counseling including visual inspection of the contents of the vial with the patient. … : a review of the evidence.

3524. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-12/spotlight_case_csf_leak_after_elective_spine_surgery_slides_-_final.pptx
      January 01, 2024 - Immediately after the operation, the surgeon informed the patient and instructed him to lie flat on his … On POD 25, the wound appeared to have dehisced, and the patient was readmitted to the hospital for advanced … 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.

3525. In Conversation with…Pat Croskerry, MD, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-withpat-croskerry-md-phd
      June 01, 2010 - Pat Croskerry : The simple answer is that I really wasn't aware of the issue until I became the head … The primary problem is the level of uncertainty. … performance of the physician about 90% of the time. … 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

3526. African Partnerships for Patient Safety: Lessons Learned | PSNet
      psnet.ahrq.gov/perspective/african-partnerships-patient-safety-lessons-learned
      December 01, 2014 - program design (2009–2011) Unlike other patient safety initiatives to date, APPS sought to catalyze change … patient safety efforts, allowing partnership implementation experiences to catalyze wider change. … the US? … The basic elements of the protocol are all the same. … , let's say in the last 5 years in the safety field?

3527. The "Customer" Is Always Right | PSNet
      psnet.ahrq.gov/web-mm/customer-always-right
      January 22, 2014 - While the rash improved, the patient developed diarrhea and low-grade fever, prompting a visit to the … He attributed the child's unsteadiness to the Benadryl, perhaps exacerbated by the viral infection. … Frustrated with the sequence of events, the mother felt that her concerns at the first visit were not … with providers, the quality of the interaction, and the perceived quality of care received. … Their Transforming Care at the Bedside effort is a framework for change on medical/surgical units built

3528. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72563/psn-pdf
      December 07, 2020 - How can we change the practice of those dentists with higher rates of prescribing either opioids or … In the United States, the CDC published a document called the CDC Core Elements of Outpatient Antibiotic … dentistry, pharmacy, and the co-directors of the antimicrobial stewardship program at the health system … We found that the patients randomized to the intervention took fewer tablets of the opioid analgesic … The workflow is different and the management is different.

3529. Too Tight Control | PSNet
      psnet.ahrq.gov/web-mm/too-tight-control
      March 20, 2013 - The orthopedic resident notified the cross-covering medicine resident that the patient would be taken … to the operating room (OR) the following day. … In preparation for the operation, the orthopedic service made the patient "NPO after midnight." … In this case, the orthopedic surgeon wrote the NPO order, and did not notice the insulin drip. … June 16, 2011 Getting teams to talk: development and pilot implementation of a checklist

3530. Inadequate Preanesthetic Evaluation, Airway Trouble | PSNet
      psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
      November 01, 2023 - 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

3531. Complications of Vascular Access Procedures in Patients with Kidney Disease | PSNet
      psnet.ahrq.gov/web-mm/complications-vascular-access-procedures-patients-kidney-disease
      November 15, 2023 - The Cases Three patients were at the same hospital over the course of a few months for vascular access … 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

3532. In Conversation With... James P. Bagian, MD, PE | PSNet
      psnet.ahrq.gov/perspective/conversation-james-p-bagian-md-pe
      February 26, 2025 - 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 … Within 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.

3533. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49639/psn-pdf
      November 01, 2011 - Fortunately, the patient's heart rate improved while he was in the ED, and the plan was to discharge … The pharmacist came to the ED to teach the patient how to do the subcutaneous LMWH injections, which … At the level of the patient, errors included the failure to recognize the difference between the atropine … For example, the nurse discharging the patient from the ED might have asked the patient to show her/ … in the incident, including the ED physician, the ED nurse, and the pharmacist.(9,10) The investigation

3534. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49865/psn-pdf
      June 01, 2019 - On the day of presentation, the patient arrived at the infusion center for a scheduled platelet transfusion … , the delayed antibiotic administration likely contributed to the death. … The Commentary by Kimberly G. … If there is no reaction, then the penicillin allergy is deleted from the record. … Redesigning the allergy module of the electronic health record.

3535. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49741/psn-pdf
      September 01, 2015 - In this case, at the first visit to the ED, the combination of abdominal pain, nausea, and vomiting … due to the laxity of the anterior abdominal wall.(10) As the uterus enlarges and fills the peritoneal … Moreover, as the distance between the peritoneum and the appendix increases, peritoneal signs may be … the diagnosis of appendicitis early in the evaluation. … The error (delay in diagnosis) led to a catastrophic adverse event—the loss of the fetus.

3536. An Ounce of Prevention | PSNet
      psnet.ahrq.gov/web-mm/ounce-prevention
      February 17, 2011 - On the second postoperative day, the patient suffered a sudden cardiopulmonary arrest. … Trauma, particularly of the lower extremities and pelvis, increases the risk of VTE. … the upper extremity is less clear. … The ACCP recommends against the routine (ie, prophylactic) use of IVC filters in trauma patients. … After a 3-day stay in the intensive care unit, the patient was transferred to the floor.

3537. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49528/psn-pdf
      January 01, 2015 - While the rash improved, the patient developed diarrhea and low-grade fever, prompting a visit to the … He attributed the child's unsteadiness to the Benadryl, perhaps exacerbated by the viral infection. … Frustrated with the sequence of events, the mother felt that her concerns at the first visit were not … After examining the ankle, the provider determines that the findings are consistent with a sprain and … Their Transforming Care at the Bedside effort is a framework for change on medical/surgical units built

3538. The Hazards of Distraction: Ticking All the EHR Boxes | PSNet
      psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
      April 09, 2014 - The Hazards of Distraction: Ticking All the EHR Boxes. PSNet [internet]. … 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

3539. New Oral Anticoagulants | PSNet
      psnet.ahrq.gov/web-mm/new-oral-anticoagulants
      July 01, 2011 - 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

3540. Perils in Diagnosing a Stroke | PSNet
      psnet.ahrq.gov/web-mm/perils-diagnosing-stroke
      August 15, 2017 - In the emergency department, the physician suspected a stroke given the patient's risk factors and the … After the thrombolytic was administered, the patient's nurse noticed multiple patches on the patient's … The nurse alerted the physician, who realized that the opioid overdose probably explained the patient's … set by the policies and protocols of the institution. … It is reasonable to preliminarily suspect stroke in a patient with risk factors and an acute change in