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psnet.ahrq.gov/issue/misdiagnosis-more-common-drug-errors-or-wrong-site-surgery
March 13, 2013 - This newspaper article discusses the pervasive problem of diagnostic errors and reveals insights from … December 14, 2016
The other big drug problem: older people taking too many pills.
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psnet.ahrq.gov/issue/inappropriate-opioid-prescription-after-surgery
February 02, 2022 - concern , this commentary summarizes clinician, patient , and systemic factors that contribute to the problem … April 17, 2019
The $17.1 billion problem: the annual cost of measurable medical errors
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psnet.ahrq.gov/issue/reporting-and-second-order-problem-solving-can-turn-short-term-fixes-long-term-remedies
May 07, 2018 - Newspaper/Magazine Article
Reporting and second-order problem solving can turn short-term … Citation Text:
Reporting and second-order problem solving can turn short-term fixes into long-term … Cite
Citation
Citation Text:
Reporting and second-order problem
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psnet.ahrq.gov/issue/organizational-learning-experience-high-hazard-industries-problem-investigations-line
May 24, 2016 - Book/Report
Organizational Learning from Experience in High-Hazard Industries: Problem … Citation Text:
Organizational Learning from Experience in High-Hazard Industries: Problem Investigations … Citation
Citation Text:
Organizational Learning from Experience in High-Hazard Industries: Problem
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psnet.ahrq.gov/issue/hospitals-installed-more-sinks-stop-infections-sinks-can-make-problem-worse
October 05, 2016 - The sinks can make the problem worse. … The sinks can make the problem worse. Branswell H. STAT. October 25, 2016. … The sinks can make the problem worse. Branswell H. STAT. October 25, 2016.
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psnet.ahrq.gov/issue/tell-truth-whole-truth-may-do-patients-harm-problem-nocebo-effect-informed-consent
October 03, 2018 - Commentary
To tell the truth, the whole truth, may do patients harm: the problem … To tell the truth, the whole truth, may do patients harm: the problem of the nocebo effect for informed … To tell the truth, the whole truth, may do patients harm: the problem of the nocebo effect for informed
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psnet.ahrq.gov/issue/diagnostic-error-medicine
October 22, 2013 - of 12 articles drawn from a 2008 conference on diagnostic error , covering topics such as medical problem … Related Resources From the Same Author(s)
Diagnostic Error: Is Overconfidence the Problem
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psnet.ahrq.gov/issue/quality-safety-and-noninterpretive-skills
November 11, 2015 - Increased radiation exposure has emerged as a patient safety problem , with the potential to result … November 11, 2015
Organizational Learning from Experience in High-Hazard Industries: Problem
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psnet.ahrq.gov/issue/problem-engaging-hospital-doctors-promoting-safety-and-quality-clinical-care
August 18, 2017 - Review
The problem of engaging hospital doctors in promoting safety and quality in … The problem of engaging hospital doctors in promoting safety and quality in clinical care. … The problem of engaging hospital doctors in promoting safety and quality in clinical care.
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psnet.ahrq.gov/issue/older-adults-are-often-misdiagnosed-specialized-ers-and-trained-clinicians-can-help
July 28, 2021 - Missed or delayed diagnosis in older people is a problem fed by clinical and social complexities. … April 26, 2023
A doctor gave me an inept diagnosis for a neurological problem.
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psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-complications-after-gastric-bypass-surgery
September 25, 2019 - to be solved at one point in time, rather than a recurring and evolving problem that is influenced by … From a psychological standpoint, problem representation can be conceived in two ways. 11 First, and … The second way to conceive of problem representation is as an individual’s mental representation of a … The importance of early problem representation during case presentations. … Reasoning on rounds: summary statement or problem representation?
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psnet.ahrq.gov/issue/human-factors-engineering-healthcare-systems-problem-human-error-and-accident-management
June 13, 2011 - Commentary
Human factors engineering in healthcare systems: the problem of human … Human factors engineering in healthcare systems: the problem of human error and accident management. … Human factors engineering in healthcare systems: the problem of human error and accident management.
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psnet.ahrq.gov/issue/implicit-bias-stroke-care-recurring-old-problem-rising-incidence-young-stroke
June 08, 2010 - Review
Implicit bias in stroke care: a recurring old problem in the rising incidence … Implicit bias in stroke care: A recurring old problem in the rising incidence of young stroke. … Implicit bias in stroke care: A recurring old problem in the rising incidence of young stroke.
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psnet.ahrq.gov/issue/evaluating-patient-safety-learning-laboratory-create-interdisciplinary-ecosystem-health-care
December 21, 2022 - Patient safety learning laboratories (PSLL) encourage a cross-disciplinary, collaborative approach to problem … June 24, 2009
Indication alerts to improve problem list documentation.
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psnet.ahrq.gov/node/838075/psn-pdf
September 14, 2022 - Crisis recovery in surgery: error management and
problem solving in safety-critical situations. … Crisis recovery in surgery: error management and problem
solving in safety-critical situations. … https://psnet.ahrq.gov/issue/crisis-recovery-surgery-error-management-and-problem-solving-safety-critical … situational awareness and
workload management; checklists for non-normal situations; decision making and problem … https://psnet.ahrq.gov/issue/crisis-recovery-surgery-error-management-and-problem-solving-safety-critical-situations
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psnet.ahrq.gov/node/866638/psn-pdf
September 04, 2024 - The problem with 'never events'.
September 4, 2024
Zaslow J, Fortier J, Garber G. … The problem with ‘never events’. BMJ Qual Saf. 2024;33(9):613-616.
doi:10.1136/bmjqs-2023-016981. … https://psnet.ahrq.gov/issue/problem-never-events
Never events are serious, but preventable, adverse … https://psnet.ahrq.gov/issue/problem-never-events
https://psnet.ahrq.gov/primer/never-events
https://
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psnet.ahrq.gov/issue/mr-smiths-been-our-problem-child-today-anticipatory-management-communication-amc-va-end-shift
January 22, 2016 - Study
"Mr Smith's been our problem child today... … "Mr Smith's been our problem child today…": anticipatory management communication (AMC) in VA end-of-shift … "Mr Smith's been our problem child today…": anticipatory management communication (AMC) in VA end-of-shift
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psnet.ahrq.gov/node/866352/psn-pdf
July 24, 2024 - Patient falls in the operating room: why is this still a
problem in 2024? … Patient falls in the operating room: why is this still a problem in 2024? … https://psnet.ahrq.gov/issue/patient-falls-operating-room-why-still-problem-2024
Patient falls are a … https://psnet.ahrq.gov/issue/patient-falls-operating-room-why-still-problem-2024
https://psnet.ahrq.gov
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psnet.ahrq.gov/issue/ethical-issues-patient-safety
November 02, 2014 - follow safe practices, respond to adverse events and to the injured patient, and take responsibility for problem … December 23, 2008
Problem doctors: is there a system-level solution?
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psnet.ahrq.gov/issue/evaluation-problem-specific-sbar-tool-improve-after-hours-nurse-physician-phone-communication
December 30, 2014 - Study
Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician … Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician phone communication … Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician phone communication