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digital.ahrq.gov/ahrq-funded-projects/information-needs-homecare-nurses-during-admission-and-care-planning/citation/problem
January 01, 2023 - There's a problem with the problem list: Incongruence of patient problem information across the home … There's a problem with the problem list: Incongruence of patient problem information across the home
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psnet.ahrq.gov/issue/problem-checklists
March 29, 2023 - Commentary
The problem with checklists. … The problem with checklists. BMJ Qual Saf. 2015;24(9):545-9. doi:10.1136/bmjqs-2015-004431. … The problem with checklists. BMJ Qual Saf. 2015;24(9):545-9. doi:10.1136/bmjqs-2015-004431.
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/problem
January 01, 2023 - Problem Solving
Kepner-Tregoe Matrix
Description
A Kepner-Tregoe … matrix is used to find causes of a problem. … This allows you to compare what the problem is, with what it is not, illuminating distinctive features … of the problem and pointing out its potential causes. … 5W2H
Description
5W2H is a tool that provides guiding questions when assessing a process or problem
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digital.ahrq.gov/ahrq-funded-projects/information-needs-homecare-nurses-during-admission-and-care-planning/citation/incongruence
January 01, 2023 - Incongruence of patient problem information across three phases of home care admission: there's a problem … with the problem list. … Incongruence of patient problem information across three phases of home care admission: there's a problem … with the problem list.
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www.ahrq.gov/practiceimprovement/delivery-initiative/mccannon/index.html
December 01, 2020 - The Spread Problem
Slide Presentation by Joe McCannon
On February 17, Joe McCannon made this … Sign up: Quality Measure Tools Email updates
Slide 1
The Spread Problem
The Challenge and Promise … for Medicare and Medicaid Services
February 17, 2011
Slide 2
Ground to Cover
The Spread Problem … Slide 15
Framing
Problem definition.
Explicit aim-setting.
Tacit aim-setting.
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/potential-problem-analysis
January 01, 2023 - Potential Problem Analysis
Acronym
PPA
Description
A potential problem analysis … The problem causes are rated according to their likelihood of occurrence and the severity of their consequences … When a problem may occur.
When the schedule for the plan's completion is significant. … ESTIMATE THE RISK of each problem by assigning it a high, medium, or low rating for both its likelihood
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psnet.ahrq.gov/issue/problem-preventable-deaths
July 24, 2024 - Commentary
The problem with preventable deaths. … The problem with preventable deaths. … The problem with preventable deaths.
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www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hospital-readmission-problem.pdf
June 02, 2025 - Hospital Readmissions: Not Just a Problem for Medicare
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Medicaid … www.ahrq.gov/cusptoolkit
Hospital Readmissions: Not Just a Problem for Medicare
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psnet.ahrq.gov/issue/medication-overload-americas-other-drug-problem
April 01, 2020 - Book/Report
Medication Overload: America's Other Drug Problem. … Citation Text:
Medication Overload: America's Other Drug Problem. Brownlee S; Garber J. … Overprescribing is a common problem that contributes to patient harm. … culture of prescribing, deficits in information and knowledge, and fragmented care contribute to the problem … Cite
Citation
Citation Text:
Medication Overload: America's Other Drug Problem
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psnet.ahrq.gov/issue/problem-root-cause-analysis
August 28, 2024 - Commentary
The problem with root cause analysis. … The problem with root cause analysis. … The problem with root cause analysis.
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www.ahrq.gov/topics/sleep-problems.html
Topic: Sleep Problems
K Award Grantee Interview: Christopher Landrigan, M.D., M.P.H.
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psnet.ahrq.gov/issue/problem-incident-reporting
February 28, 2024 - Commentary
The problem with incident reporting. … The problem with incident reporting. … The problem with incident reporting.
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psnet.ahrq.gov/issue/persistent-problem-diagnostic-error
July 17, 2013 - Newspaper/Magazine Article
The persistent problem of diagnostic error. … Citation Text:
The persistent problem of diagnostic error. Lundberg GD. Medscape. … author's experience with autopsies to provide context regarding diagnostic errors as a patient safety problem … Copy URL
Cite
Citation
Citation Text:
The persistent problem
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/problem-solving-fac-notes.html
June 01, 2017 - Slide 3: What Is a Problem? What Is a Solution? … Often, it is appropriate to apply type 2 problem solving to understand why the problem occurred and then … When problem solving prevents organizational learning. … This is problem solving and escalation in action. … Turning to problem solving:
A first test—can you assign a problem to one of the four boxes and follow
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/problem-solving-comp-kit.html
June 01, 2017 - What Are Problem Solving and Escalation?
2. What Is a Problem and What Is a Solution?
3. … What Are Problem Solving and Escalation? … Problem Triage
Imagine that a staff member identifies a problem. … Issue symptomatic of a larger problem : In some cases, it will be clear that the problem is symptomatic … Such a problem will require deeper analysis to understand the root problems and the problem may require
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psnet.ahrq.gov/issue/indication-alerts-improve-problem-list-documentation
July 28, 2021 - Study
Indication alerts to improve problem list documentation. … Indication alerts to improve problem list documentation. … Problem lists , while an important part of high-quality care, are frequently incomplete or lack accuracy … on the problem list) in two different hospitals using different EHRs. … Indication alerts to improve problem list documentation.
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/problem-solving-slides.html
June 01, 2017 - Management Practices for Sustainability Module 3: Problem Solving and Escalation
Slide 1: Management … Slide 3: What Is a Problem? What Is a Solution? … (3) Problem: Less than 100 percent of team gave an audible check. … Try the Problem Triage flowchart as your initial guide. … If your organization has a standard problem-solving method, learn to use it.
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psnet.ahrq.gov/issue/problem-never-events
July 12, 2023 - Commentary
The problem with 'never events'. … The problem with ‘never events’. BMJ Qual Saf. 2024;33(9):613-616. doi:10.1136/bmjqs-2023-016981. … The problem with ‘never events’. … August 7, 2024
Patient falls in the operating room: why is this still a problem in 2024
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psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
October 19, 2022 - SPOTLIGHT CASE
Resuscitation Errors: A Shocking Problem
Citation Text:
Edelson … Resuscitation Errors: A Shocking Problem. PSNet [internet]. … Resuscitation Errors: A Shocking Problem. PSNet [internet]. … more than 300,000 lives each year in the United States alone.( 1 ) SCA presents a difficult clinical problem … Resuscitation Errors: A Shocking Problem. PSNet [internet].
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psnet.ahrq.gov/issue/cms-your-mistake-your-problem
November 16, 2022 - Newspaper/Magazine Article
CMS: your mistake, your problem. … CMS: your mistake, your problem. Eight hospital-acquired conditions won't be paid for. … CMS: your mistake, your problem. Eight hospital-acquired conditions won't be paid for.