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digital.ahrq.gov/sites/default/files/docs/page/Systems%20Analysis,%20Change%20and%20Implementaion%20Theories.pdf
June 16, 2021 - system in a particular
organization at a particular time
• Be piecemeal, no systems approach
• Lack … context
• Have unmet data needs
• Be doubtful regarding implementation, scalability, transferability
• Lack … significant policy implications
• Lack a “National Owner” with a clear vision
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Cont.:
• Lack
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/teledx-table1.html
August 01, 2020 - Disadvantaged patients may lack internet access or video-chat tools. … Safety may be reduced by missed physical findings, lack of presence, and decreased participation of onsite
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psnet.ahrq.gov/issue/accidents-and-incidents-related-intravenous-drug-administration-pre-post-study-following
September 24, 2016 - This lack of benefit from smart pumps indicates the need for human factors approaches to characterize … May 5, 2018
Lack of standard dosing methods contributes to IV errors.
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digital.ahrq.gov/ahrq-funded-projects/harnessing-health-information-technology-prevent-medication-induced-birth/annual-summary/2010
January 01, 2010 - At the provider level, barriers included: pregnancy risk; lack of knowledge, training, or comfort; beliefs … responsibility for initiating discussions; a need for skilled personnel for certain contraceptive methods; and a lack … Finally, health system level challenges regarding contraceptive counseling included lack of insurance … trained to fit or insert contraceptive devices, competing medical priorities, visit type, case mix, and lack
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effectivehealthcare.ahrq.gov/sites/default/files/protocol-social-isolation.pdf
January 01, 2013 - psychological and physical outcomes, as well as
increased mortality.1,2 Social isolation is defined as the lack … of meaningful and sustained
connection to other people, while loneliness is defined as a perceived lack … become socially isolated, including visual and hearing disabilities, the desire
to be independent, lack … of mobility, loss of family and friends, and lack of transportation.
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www.ahrq.gov/sites/default/files/2024-07/bates2-report.pdf
January 01, 2024 - These include
system barriers such as inadequate resources, physician barriers such as lack of knowledge … or
lack of time, and patient barriers such as misunderstandings or noncompliance. … We found that
the most common barriers to guideline adherence reported by PCPs included lack of time … during patient visits (51%), patient noncompliance (42%), lack of guideline knowledge
(35%), and … during patient visits (51%), patient non compliance
(42%), lack of guideline knowledge (35%), and
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psnet.ahrq.gov/node/41066/psn-pdf
October 16, 2012 - The reasons for this lack of
reporting likely include confusion about which types of errors needed to … be reported, as well as other issues
documented in prior studies such as lack of reporting by physicians
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meps.ahrq.gov/data_files/publications/st461/stat461.shtml
November 01, 2014 - Hispanic adults ages 18-64 were the most likely to lack a usual source of care in comparison to other … Men and women ages 18–34 were the most likely to lack a USC, at 46.6 percent and 32.3 percent, respectively … Women ages 45–64 were least likely to lack a USC in 2012 (13.3 percent). … Non-Hispanic white women were least likely to lack a USC in 2012 (18.7 percent). … Women ages 18 to 64 who had private health insurance were the least likely to lack a USC (16.6 percent
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-201-indoor-allergen-reduction-asthma-evidence-summary.pdf
February 01, 2018 - multicomponent
interventions intended to reduce allergen exposure
improve asthma outcomes is limited by a lack … • Qualitative comparative analysis affirmed the general
lack of robust findings of improved outcome … The overall evidence base is characterized by a lack of
conclusive, consistent, high- or moderate-strength … However, we note the critical distinction between a
lack of evidence and evidence of no effect. … Moreover, results that were conclusive tended
to suggest lack of clinical effect.
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psnet.ahrq.gov/node/41935/psn-pdf
December 19, 2012 - results-effort-integrate-quality-and-safety-medical-and-nursing-school-
curricula-and-foster
A seminal 2009 report describes the lack … Although the institutions
encountered many challenges—including a lack of faculty expertise in patient
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psnet.ahrq.gov/node/38674/psn-pdf
February 17, 2011 - However, due to a lack
of clear evidence on the safety effects of duty-hour reduction, the authors were … The accompanying editorial notes the
relative lack of evidence supporting additional duty-hour reductions
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psnet.ahrq.gov/node/39031/psn-pdf
March 23, 2011 - factors: polypharmacy, overworked staff,
poor communication between nursing home staff and physicians, lack … of a culture of safety, and lack of
reliable systems for medication ordering and administration.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/James.pdf
January 01, 2004 - Some members of the original
IOM committee have publicly decried the lack of substantial progress,2, … A lack of appreciation of the true incidence and nature of patient
injuries leads to “unscientific theories … There is a lack of a business case for safety, to justify and offset the
large investments that may
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psnet.ahrq.gov/innovation/let-us-twisst-plan-simulate-study-and-act
October 12, 2018 - Seventeen percent of these were considered ‘high’ or ‘very high’ priority conditions, such as lack of … standardized preparation for intubation, lack of available respiratory supplies in the trauma bay, and … lack of space for medication preparation.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Johnson_90.pdf
June 10, 2008 - required by the ACGME
as one of the core competencies that residents must demonstrate, there is a lack … the authority or power, and they lack the
time. … Lack of assessment methods.
3. … Lack of understanding of the relationship of SBP to patient outcomes and safety.
4. … Lack of integration into daily practice.
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psnet.ahrq.gov/issue/care-homes-use-medicines-study-prevalence-causes-and-potential-harm-medication-errors-care
April 22, 2011 - : polypharmacy , overworked staff, poor communication between nursing home staff and physicians, lack … of a culture of safety , and lack of reliable systems for medication ordering and administration.
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psnet.ahrq.gov/issue/cost-implications-reduced-work-hours-and-workloads-resident-physicians
August 05, 2015 - However, due to a lack of clear evidence on the safety effects of duty-hour reduction, the authors … The accompanying editorial notes the relative lack of evidence supporting additional duty-hour reductions
-
psnet.ahrq.gov/issue/supratherapeutic-dosing-acetaminophen-among-hospitalized-patients
February 14, 2017 - outpatient setting, unintentional acetaminophen overdose has been linked to poor health literacy and lack … provider order entry systems, and the authors note that existing clinical decision support systems lack
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/creating-safety-culture/cultureofsafety_hemodialysis.pptx
September 03, 2014 - of time
Lack of information sharing
Hierarchy
Varying communication styles
Presence of conflict
Lack … of time and information sharing
Hierarchy
Varying communication styles
Conflict
Lack of coordination … and followup
Misinterpretation of cues
Lack of role clarity
Inconsistency in team membership limits … Teams that lack sufficient structure with a wide variety of input or that lack fully involved members … , and lack of role clarity.
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psnet.ahrq.gov/primer/discharge-planning-and-transitions-care
June 15, 2024 - Hospital discharges are complicated and often lack standardization. … hospitalizations) than those who did not. 9 Challenges to understanding discharge instructions include patients’ lack … factors associated with nonadherence should be addressed throughout the hospitalization, including lack … understanding or confusion about needed care, transportation, and how to schedule appointments. 12 Lack … knowing who and when to follow up with when there are multiple providers. 3 In addition, there can be a lack