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Showing results for "the change teams".

3541. Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation | PSNet
      psnet.ahrq.gov/web-mm/bandemia-harbinger-stercoral-colitis-and-impending-perforation
      November 25, 2020 - The Case A 56-year-old woman was brought to the emergency department (ED) by her husband for “shaking … During observation in the ED, the patient’s condition improved considerably with intravenous fluids, … the ischemic pathophysiology, perforations typically occur in the antimesenteric aspect of the bowel … Management The management of stercoral colitis depends on the clinical status of the patient. … Review of a large clinical series: is the band count useful in the diagnosis of infection?

3542. In Conversation with…Sanjay Saint, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-withsanjay-saint-md-mph
      November 01, 2008 - And so we all went on the other side of the bed, lifted up the sheet, and saw that there was a catheter … As I recall, there's a study that just came out that looked at that connection and did not find a change … in the middle of the night, they might not realize that the catheter is draining their bladder. … , and that the large drape be either in the kit or be part of the central venous catheter kit. … the bladder within the biofilm.

3543. Health Care–Acquired Urinary Tract Infection: The Problem and Solutions | PSNet
      psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
      November 01, 2008 - the bladder within the biofilm. … As the use of a catheter and the duration of catheter use are the most important determinants of cUTI … As I recall, there's a study that just came out that looked at that connection and did not find a change … in the middle of the night, they might not realize that the catheter is draining their bladder. … , and that the large drape be either in the kit or be part of the central venous catheter kit.

3544. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33796/psn-pdf
      January 01, 2016 - 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 … But in some ways the promise held out over the last 30 years was ultimately that we wouldn't need the … One of them is the old yellow pen, the test on the boards and in other places where you went down a … The second is the oral exam, which I think is still done in the UK but is long gone in medicine in the

3545. In Conversation With... David Gruen, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-david-gruen-md
      January 31, 2020 - The change in paradigm is going to encourage radiologists to slow down and take more time to ensure they … If, on the other hand, at the time of the exam AI can analyze the image and alert the radiology technologists … The radiologist sees the nodule and lets the ED [emergency department] doc know. … The truth and proof is in the use of pathology. … AI systems are not as equipped as humans to recognize when there is a relevant change in context or data

3546. Artificial Intelligence and Diagnostic Errors | PSNet
      psnet.ahrq.gov/perspective/artificial-intelligence-and-diagnostic-errors
      January 31, 2020 - AI systems are not as equipped as humans to recognize when there is a relevant change in context or data … The change in paradigm is going to encourage radiologists to slow down and take more time to ensure they … If, on the other hand, at the time of the exam AI can analyze the image and alert the radiology technologists … The radiologist sees the nodule and lets the ED [emergency department] doc know. … The truth and proof is in the use of pathology.

3547. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865419/psn-pdf
      March 27, 2024 - Identify tools to assist the clinician in recognizing sepsis in the pediatric patient. … The treating physician did not mention pneumonia in the differential diagnosis. … On day 3 after the first ED visit, the child was brought back to the ED by ambulance with pulseless … If the suspected etiology is viral, as in the patient’s initial presentation, the typical practice is … During the above patient’s second ED visit, the patient’s vital signs suggested the potential for worsening

3548. Do Not Miss Sepsis Needles in Viral Haystacks! | PSNet
      psnet.ahrq.gov/web-mm/do-not-miss-sepsis-needles-viral-haystacks
      March 27, 2024 - Identify tools to assist the clinician in recognizing sepsis in the pediatric patient. … The treating physician did not mention pneumonia in the differential diagnosis. … On day 3 after the first ED visit, the child was brought back to the ED by ambulance with pulseless electrical … If the suspected etiology is viral, as in the patient’s initial presentation, the typical practice is … During the above patient’s second ED visit, the patient’s vital signs suggested the potential for worsening

3549. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853774/psn-pdf
      September 27, 2023 - The ED physician informed the assigned nurse that the patient was in critical condition. … The reason for the triage delay is unclear, but triage can easily back up when the ED is busy, given … Although the primary mission of the ED is to treat life-threatening emergencies, the modern ED serves … With the closure of many state-funded mental health hospitals in the 1980s, EDs are on the front lines … of bleeding or the source of sepsis) would offer the only real possibility of interrupting the patient

3550. Delayed Evaluation of Abdominal Pain in an Elderly Patient. | PSNet
      psnet.ahrq.gov/web-mm/delayed-evaluation-abdominal-pain-elderly-patient
      February 26, 2020 - The ED physician informed the assigned nurse that the patient was in critical condition. … Split flow models of care assure patients receive the right resources in the right location at the right … The reason for the triage delay is unclear, but triage can easily back up when the ED is busy, given … Although the primary mission of the ED is to treat life-threatening emergencies, the modern ED serves … With the closure of many state-funded mental health hospitals in the 1980s, EDs are on the front lines

3551. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2024-03/final_spotlight_case_not_missing_sepsis_needles_in_viral_haystacks_slides_march_date.pdf
      January 01, 2024 - Source and Credits • This presentation is based on the March 2024 AHRQ WebM&M Spotlight Case o See the … The treating physician did not mention pneumonia in the differential diagnosis. 5 Case Details ( … after the first ED visit, the child was brought back to the ED by ambulance with pulseless electrical … • If the suspected etiology is viral, as in the patient’s initial presentation, the typical practice … • The goal of early sepsis recognition is the rapid implementation of appropriate treatment.

3552. Implementing a Fall Prevention Program | PSNet
      psnet.ahrq.gov/perspective/implementing-fall-prevention-program
      November 29, 2023 - of the problem. … But, we can certainly decrease the frequency of falls as well as the chances that falls that do occur … But, what interventions within the multifactorial "bundle" appear to be the most effective? … The scale of the challenge can perhaps best be faced by setting aside the question, "How do we prevent … Learning from preventable deaths: exploring case record reviewers' narratives using change

3553. Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia | PSNet
      psnet.ahrq.gov/web-mm/multiple-high-risk-events-involving-workflow-wasting-medications-used-anesthesia
      August 29, 2021 - placed this fentanyl syringe in the pocket of the automated dispensing cabinet (ADC) and notified the … resident of the need to waste the medication. … The resident mistakenly removed the syringe to be wasted from the ADC pocket during the procedure and … utilize the “rights of medication administration”, with the classic five rights being: the right patient … , the right drug, the right dose, the right route, and the right time. 9 However, the medication-use

3554. Pre-analytical pitfalls: Missing and mislabeled specimens | PSNet
      psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
      April 18, 2018 - The samples were dropped off at the central laboratory receiving window where the time/date of receipt … Both the central laboratory and satellite facility were not aware that the sample was missing until the … The ordering physician was notified of the missing sample. … The Emergency Medicine physician contacted the Laboratory to determine the cause of such a large shift … Follow-up investigation by the ED ultimately revealed the initial sample with the high cardiac troponin

3555. Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks | PSNet
      psnet.ahrq.gov/web-mm/paroxysmal-supraventricular-tachycardia-masquerading-panic-attacks
      September 01, 2017 - The Case At the age of 16, an otherwise healthy woman began feeling “woozy” after her high school … the side of the road for 45 minutes until the symptoms subsided. … The Commentary By David T. … Panic attacks and supraventricular tachycardias: the chicken or the egg?  … March 4, 2011 From the flight deck to the operating room: an initial pilot study of the

3556. Near Miss with Bedside Medications | PSNet
      psnet.ahrq.gov/web-mm/near-miss-bedside-medications
      February 01, 2006 - 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 … of an incident: whether the incident reached the patient and whether the patient was harmed. … For example, the nurse discharging the patient from the ED might have asked the patient to show her/him … in the incident, including the ED physician, the ED nurse, and the pharmacist.( 9,10 ) The investigation

3557. Abdominal Pain in Early Pregnancy | PSNet
      psnet.ahrq.gov/web-mm/abdominal-pain-early-pregnancy
      November 13, 2024 - With the exception of ovarian torsion, which is more common in the first trimester, the cause and incidence … 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 algorithm should take into account best practices as well as the expertise and capability of the … The error (delay in diagnosis) led to a catastrophic adverse event—the loss of the fetus.

3558. In Conversation With… Edward Kelley, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-edward-kelley-phd
      December 01, 2014 - the US? … Part of the challenge we face at WHO is we had lots of activity with partners in the US and in the UK … The basic elements of the protocol are all the same. … 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.

3559. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867429/psn-pdf
      December 18, 2024 - Immediately after the operation, the surgeon informed the patient and instructed him to lie flat on … 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.

3560. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49813/psn-pdf
      January 01, 2018 - After communication with the family, the patient's care was transitioned to a focus on comfort and the … to arrival at the patient's home, her resuscitation, intubation, and transfer to the hospital in the … an appointment reminder, and the family replied that the patient had died. … 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