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Total Results: 1,785 records

Showing results for "problem".

161. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867497/psn-pdf
     February 26, 2025 - could not have been true) in 40 of the 46 (87%) retained sponge cases.4 There must have been some problem … In these cases, counting identified a problem but communication failed. … This problem is called normalization of deviance and may drive unhealthy cultural responses (e.g., “ … false positive counts are exceedingly common in the management of suture needles.7 This is a practice problem … Retained surgical items: overview of a persistent problem in health care.

162. Managing disruptive behaviors in the health care setting: focus on obstetrics services. | PSNet
     psnet.ahrq.gov/issue/managing-disruptive-behaviors-health-care-setting-focus-obstetrics-services
     February 03, 2010 - August 27, 2012 Perspective How to Identify and Manage Problem … September 1, 2010 Perspective How to Identify and Manage Problem

163. The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation | PSNet
     psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-diagnostic-accuracy
     April 01, 2005 - Summary Addressing diagnostic errors to improve outcomes and patient safety has long been a problem … Date First Implemented 2010 Problem Addressed Diagnostic errors are … a difficult problem. 1 The 2015 National Academy of Medicine report found that “most people will experience … of the Innovation Solving diagnostic errors to improve outcomes and patient safety has long been a problem … Given the magnitude of the problem as outlined in the 2015 National Academy of Medicine report, 1 there

164. The emotional impact of medical errors on practicing physicians in the United States and Canada. | PSNet
     psnet.ahrq.gov/issue/emotional-impact-medical-errors-practicing-physicians-united-states-and-canada
     January 23, 2008 - Very few physicians felt adequately supported by their employer after the incident, a problem also documented

165. Surgical team behaviors and patient outcomes. | PSNet
     psnet.ahrq.gov/issue/surgical-team-behaviors-and-patient-outcomes
     April 08, 2011 - Though suboptimal teamwork is a recognized problem in the operating room, this study is one of the

166. Cognitive errors in diagnosis: instantiation, classification, and consequences. | PSNet
     psnet.ahrq.gov/issue/cognitive-errors-diagnosis-instantiation-classification-and-consequences
     June 21, 2016 - This study analyzed 40 consecutive transcripts of problem-solving exercises to identify cognitive diagnostic

167. Incorrect surgical counts: a qualitative analysis. | PSNet
     psnet.ahrq.gov/issue/incorrect-surgical-counts-qualitative-analysis
     September 12, 2012 - In light of these findings, the authors argue that addressing the persistent problem of retained surgical

168. Building a learning organization. | PSNet
     psnet.ahrq.gov/issue/building-learning-organization
     June 16, 2011 - the author states that true learning organizations become skilled at five main activities: systematic problem

169. Government and industry fail to protect the public when they suggest "carefully following instructions" is enough to prevent vaccine errors. | PSNet
     psnet.ahrq.gov/issue/government-and-industry-fail-protect-public-when-they-suggest-carefully-following
     February 24, 2016 - April 13, 2016 Reporting and second-order problem solving can turn short-term fixes into … The sinks can make the problem worse.

170. Strategies and Approaches for Investigating Patient Safety Events | PSNet
     psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
     March 15, 2025 - Root Cause Analysis Root cause analyses (RCAs) are problem-solving tools and techniques used to retrospectively … in how RCA is employed in organizations to improve patient safety, common steps include defining the problem … Root Cause Analysis: The Core of Problem Solving and Corrective Action, Second Edition.

171. Accountability in Patient Safety | PSNet
     psnet.ahrq.gov/perspective/accountability-patient-safety
     January 01, 2018 - three large-scale failures at the National Health Service, offers a prominent illustration of this problem … little doubt that disruptive behaviors harm patients, work environments, and staff morale, and that the problem … A prior PSNet perspective summarizes a stepwise approach for managing problem behaviors. … 1, 2018 Perspective Overuse as a Patient Safety Problem

172. Initial clinical evaluation of a handheld device for detecting retained surgical gauze sponges using radiofrequency identification technology. | PSNet
     psnet.ahrq.gov/issue/initial-clinical-evaluation-handheld-device-detecting-retained-surgical-gauze-sponges-using
     August 18, 2010 - November 6, 2013 Application of an engineering problem-solving methodology to address … September 25, 2013 Retained surgical items: a problem yet to be solved.

173. Changing the "working while sick" culture. | PSNet
     psnet.ahrq.gov/issue/changing-working-while-sick-culture
     March 14, 2018 - The authors recommend strategies and policies to address this problem, including promoting professionalism

174. Tying up loose ends: discharging patients with unresolved medical issues. | PSNet
     psnet.ahrq.gov/issue/tying-loose-ends-discharging-patients-unresolved-medical-issues
     February 24, 2011 - Recognition of this problem has led to the development of formal discharge checklists to ensure optimal

175. Medical errors involving trainees: a study of closed malpractice claims from 5 insurers. | PSNet
     psnet.ahrq.gov/issue/medical-errors-involving-trainees-study-closed-malpractice-claims-5-insurers
     July 10, 2008 - accompanying editorial discusses a dramatically new model for inpatient care that would begin to address the problem

176. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867773/psn-pdf
     February 01, 2024 - This checklist targets the persistent problem of central line-associated infections by providing critical

177. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33776/psn-pdf
     January 01, 2015 - But all of the things you mention there—PDSA cycles, root cause analysis, problem solving, continuous … to look mainly at the system because there's this very human desire to put a neat little bow around problem … I can tell you, having worked at General Motors in the mid-1990s, the problem was not that people wouldn't … The problem was that managers didn't listen. … That's a pretty common problem.

178. Examining the Copy and Paste Function in the Use of Electronic Health Records. | PSNet
     psnet.ahrq.gov/issue/examining-copy-and-paste-function-use-electronic-health-records
     October 21, 2015 - The authors conclude that the problem does exist, describe its impact on situational awareness, and provide

179. In Conversation With… Michael Cohen, RPh, MS, ScD (hon) | PSNet
     psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon-0
     October 24, 2021 - MC : Well, handwriting and lookalike drug names were a big problem. … But the medication safety problem hasn't gone away, obviously. … Things like that are a problem today. … They can contact us about a problem. … You could work for half an hour on a problem and you're not going to get reimbursed one cent.

180. Diagnostic Errors | PSNet
     psnet.ahrq.gov/perspective/diagnostic-errors
     December 01, 2013 - Causes of the Problem As noted at the outset, something about diagnostic errors strikes many clinicians … reflecting individual performance, with less obvious roles for a systems approach to addressing the problem … Addressing the Problem As intellectually appealing as cognitive debiasing may be, addressing systems … If you have passion to solve a specific quality or safety problem, that's what you should do. … It really tried to bring this problem to the limelight.