Results

Total Results: 1,785 records

Showing results for "problem".

141. Quality improvement as a primary approach to change in healthcare: a precarious, self-limiting choice? | PSNet
     psnet.ahrq.gov/issue/quality-improvement-primary-approach-change-healthcare-precarious-self-limiting-choice
     June 08, 2022 - January 8, 2020 Overdiagnosis and overtreatment as a quality problem: insights from healthcare … June 19, 2018 The problem with…using stories as a source of evidence and learning.

142. A multicenter collaborative effort to reduce preventable patient harm due to retained surgical items. | PSNet
     psnet.ahrq.gov/issue/multicenter-collaborative-effort-reduce-preventable-patient-harm-due-retained-surgical-items
     March 20, 2019 - December 15, 2024 Patient falls in the operating room: why is this still a problem … September 21, 2022 Crisis recovery in surgery: error management and problem solving in

143. Examining medication ordering errors using AHRQ Network of Patient Safety Databases. | PSNet
     psnet.ahrq.gov/issue/examining-medication-ordering-errors-using-ahrq-network-patient-safety-databases
     November 30, 2022 - November 30, 2022 Indication alerts to improve problem list documentation. … April 27, 2022 Indication alerts to improve problem list documentation.

144. Distracted practice: a concept analysis. | PSNet
     psnet.ahrq.gov/issue/distracted-practice-concept-analysis
     February 27, 2009 - The authors advocate for further research to understand the impact of the problem and design solutions

145. The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety | PSNet
     psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
     October 01, 2009 - The problem of patient safety needed to be brought into sharper focus if it was going to receive the … The first, typified by To Err Is Human , involves broad, analytical pieces that tackle the general problem … But when the state inspectors went into the hospital, they discovered that it was not a problem with … Then, not only is the problem what actually happened, but the problem is that you tried to cover it up … problem.

146. Never Events | PSNet
     psnet.ahrq.gov/primer/never-events
     June 15, 2024 - However, when Never Events occur, they are devastating to patients and may indicate a fundamental safety problem … April 4, 2024 The problem with 'never events'. … September 4, 2024 Patient falls in the operating room: why is this still a problem in 2024?

147. When doctors make mistakes. | PSNet
     psnet.ahrq.gov/issue/when-doctors-make-mistakes
     September 28, 2017 - uses a harrowing personal example of a medical error to illustrate that medical mistakes are not a problem

148. Improving the bar-coded medication administration system at the Department of Veterans Affairs. | PSNet
     psnet.ahrq.gov/issue/improving-bar-coded-medication-administration-system-department-veterans-affairs
     November 18, 2009 - describes approaches to true management problems in health systems as a mechanism to share experiences and problem-solving

149. Retained Surgical Items: Definition and Epidemiology. | PSNet
     psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
     September 15, 2024 - RFO or RFB is not the result of medical error, whereas an RSI is a multi-stakeholder patient safety problem … discrepancies had not yet been resolved, and in fact, the team was using best practices to solve the problem … Increased appreciation of the problem of retained vaginal sponges and other items (e.g., vaginal packing … Needles are the most frequently miscounted surgical item, but their relative contribution to the problem … December 15, 2024 Patient falls in the operating room: why is this still a problem

150. Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement, Third Edition. | PSNet
     psnet.ahrq.gov/issue/lean-hospitals-improving-quality-patient-safety-and-employee-engagement-third-edition
     May 04, 2016 - One chapter focuses on the use of root cause problem-solving and error prevention .

151. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. | PSNet
     psnet.ahrq.gov/issue/deficits-communication-and-information-transfer-between-hospital-based-and-primary-care
     January 25, 2017 - problems between physicians at hospital discharge and to identify interventions that ameliorated this problem

152. Reducing the Safety Hazards of Monitor Alert and Alarm Fatigue | PSNet
     psnet.ahrq.gov/perspective/reducing-safety-hazards-monitor-alert-and-alarm-fatigue
     May 01, 2016 - monitor alarms are false or clinically insignificant.( 2-5 ) Hospitals are struggling to address this problem … RW : When you first began investigating this, did you have a theory as to what the problem was, and did … RW : That's just such a wonderful story that captures the essence of the problem. … BD : Alarm fatigue is probably a much bigger problem on a general medical floor than in the ICU. … September 1, 2016 Insights into the problem of alarm fatigue with physiologic monitor

153. 2008 Update on Consumers' Views of Patient Safety and Quality Information. | PSNet
     psnet.ahrq.gov/issue/2008-update-consumers-views-patient-safety-and-quality-information
     October 02, 2013 - respondents, with two-thirds of those surveyed feeling that care coordination was at least a minor problem

154. Patient Safety in Ambulance Services: A Scoping Review. | PSNet
     psnet.ahrq.gov/issue/patient-safety-ambulance-services-scoping-review
     April 19, 2017 - associated with ambulance care, this scoping review found that inconsistent use of terminology was a problem

155. Good Catch in the Operating Room | PSNet
     psnet.ahrq.gov/web-mm/good-catch-operating-room
     August 27, 2017 - An acronym for key expressions containing code words signaling a potential urgent safety problem, the … " or "This is a S afety issue," it indicates that the member wants to "stop the line" to address a problem … Third, she stated what she felt was the perceived problem of unrecognized hemorrhage. … Fourth, she offered her solution by suggesting to stop the procedure and figure out the problem. … Take-Home Points The CUS Tool can help alert other team members to a safety problem and should prompt

156. The impacts of a pharmacist-managed outpatient clinic and chemotherapy-directed electronic order sets for monitoring oral chemotherapy. | PSNet
     psnet.ahrq.gov/issue/impacts-pharmacist-managed-outpatient-clinic-and-chemotherapy-directed-electronic-order-sets
     June 18, 2014 - patients enrolled in a pharmacist-run oral chemotherapy monitoring clinic experienced a medication-related problem

157. The relationship between resident physician burnout and its’ effects on patient care, professionalism, and academic achievement: a review of the literature. | PSNet
     psnet.ahrq.gov/issue/relationship-between-resident-physician-burnout-and-its-effects-patient-care-professionalism
     December 21, 2017 - Burnout is a significant problem among medical residents .

158. The misery of a doctor's first days. | PSNet
     psnet.ahrq.gov/issue/misery-doctors-first-days
     December 02, 2015 - face, including burnout and gaps in practical experience, and describes efforts meant to address this problem

159. Medication prescribing errors involving the route of administration. | PSNet
     psnet.ahrq.gov/issue/medication-prescribing-errors-involving-route-administration
     January 12, 2011 - Error in medication prescribing is a well-described problem in the hospital setting.

160. Harm From Alarm Fatigue | PSNet
     psnet.ahrq.gov/web-mm/harm-alarm-fatigue
     February 14, 2018 - This patient's telemetry device warned of this problem with "low voltage" alarms. … alarms that indicate poor signal quality (e.g., a low battery in a telemetry device, an electrode problem … Take-Home Points Alarms should never be completely silenced; rather, clinical staff should problem-solve … Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational … October 10, 2012 Insights into the problem of alarm fatigue with physiologic monitor