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Showing results for "problem".

21. Patient falls in the operating room: why is this still a problem in 2024? | PSNet
    psnet.ahrq.gov/issue/patient-falls-operating-room-why-still-problem-2024
    May 08, 2024 - Commentary 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? … Patient falls in the operating room: why is this still a problem in 2024?

22. Laney's story: the problem of delayed diagnosis of pediatric stroke. | PSNet
    psnet.ahrq.gov/issue/laneys-story-problem-delayed-diagnosis-pediatric-stroke
    April 24, 2018 - Commentary Laney's story: the problem of delayed diagnosis of pediatric stroke. … Laney's Story: The Problem of Delayed Diagnosis of Pediatric Stroke. … Laney's Story: The Problem of Delayed Diagnosis of Pediatric Stroke.

23. Strategies for learning from failure. | PSNet
    psnet.ahrq.gov/issue/strategies-learning-failure
    September 25, 2024 - detection and reporting of problems by frontline staff, and promote experimentation and creative problem-solving … September 25, 2024 Speaking up and taking action: psychological safety and joint problem-solving … March 8, 2017 Development of "SWARM" as a model for high reliability, rapid problem solving

24. The $17.1 billion problem: the annual cost of measurable medical errors. | PSNet
    psnet.ahrq.gov/issue/171-billion-problem-annual-cost-measurable-medical-errors
    May 26, 2021 - Study Classic The $17.1 billion problem: the annual cost … The $17.1 Billion Problem: The Annual Cost Of Measurable Medical Errors. … The $17.1 Billion Problem: The Annual Cost Of Measurable Medical Errors.

25. Drug-related-problem outcomes and program satisfaction from a comprehensive brown bag medication review. | PSNet
    psnet.ahrq.gov/issue/drug-related-problem-outcomes-and-program-satisfaction-comprehensive-brown-bag-medication
    September 23, 2020 - Review Drug-related-problem outcomes and program satisfaction from a comprehensive … Drug-Related-Problem Outcomes and Program Satisfaction from a Comprehensive Brown Bag Medication Review … Drug-Related-Problem Outcomes and Program Satisfaction from a Comprehensive Brown Bag Medication Review … February 12, 2020 The problem with medication reconciliation.

26. Applying human factors engineering to address the telemetry alarm problem in a large medical center. | PSNet
    psnet.ahrq.gov/issue/applying-human-factors-engineering-address-telemetry-alarm-problem-large-medical-center
    February 10, 2021 - Study Applying human factors engineering to address the telemetry alarm problem in … Applying human factors engineering to address the telemetry alarm problem in a large medical center. … Applying human factors engineering to address the telemetry alarm problem in a large medical center. … February 10, 2021 Indication alerts to improve problem list documentation.

27. Health Care–Acquired Urinary Tract Infection: The Problem and Solutions | PSNet
    psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
    November 01, 2008 - Health Care–Acquired Urinary Tract Infection: The Problem and Solutions Lindsay E. … Health Care–Acquired Urinary Tract Infection: The Problem and Solutions. PSNet [internet]. … Health Care–Acquired Urinary Tract Infection: The Problem and Solutions. PSNet [internet]. … So it's unclear which one is more likely to be a problem. … What do you think of the accreditation and regulatory approach to this problem?

28. The Soil, Not the Seed: The Real Problem with Root Cause Analysis | PSNet
    psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
    March 01, 2007 - The Soil, Not the Seed: The Real Problem with Root Cause Analysis Patrice Spath, BA, RHIT, and William … The Soil, Not the Seed: The Real Problem with Root Cause Analysis. PSNet [internet]. … The Soil, Not the Seed: The Real Problem with Root Cause Analysis. PSNet [internet]. … If we are correct, then the RCA tool is not the problem. … The Soil, Not the Seed: The Real Problem with Root Cause Analysis. PSNet [internet].

29. The wicked problem of patient misidentification: how could the technological revolution help address patient safety? | PSNet
    psnet.ahrq.gov/issue/wicked-problem-patient-misidentification-how-could-technological-revolution-help-address
    July 10, 2024 - Commentary The wicked problem of patient misidentification: how could the technological … The wicked problem of patient misidentification: How could the technological revolution help address … The wicked problem of patient misidentification: How could the technological revolution help address

30. Teamwork- Part 1: Divided We Fall; Part 2: Cursed By Knowledge: Building a Culture of Psychological Safety; and Part 3: The Not-My-Problem Problem. | PSNet
    psnet.ahrq.gov/issue/teamwork-part-1-divided-we-fall-part-2-cursed-knowledge-building-culture-psychological-safety
    August 02, 2015 - Fall; Part 2: Cursed By Knowledge: Building a Culture of Psychological Safety; and Part 3: The Not-My-Problem … Problem.

31. Patient safety in emergency departments: a problem for health care systems? An international survey. | PSNet
    psnet.ahrq.gov/issue/patient-safety-emergency-departments-problem-health-care-systems-international-survey
    February 26, 2020 - Study Patient safety in emergency departments: a problem for health care systems? … Patient safety in emergency departments: a problem for health care systems? … Patient safety in emergency departments: a problem for health care systems?

32. A doctor gave me an inept diagnosis for a neurological problem. I should know: I’m a neurologist. | PSNet
    psnet.ahrq.gov/issue/doctor-gave-me-inept-diagnosis-neurological-problem-i-should-know-im-neurologist
    April 27, 2022 - Newspaper/Magazine Article A doctor gave me an inept diagnosis for a neurological problem … Citation Text: A doctor gave me an inept diagnosis for a neurological problem. … Citation Citation Text: A doctor gave me an inept diagnosis for a neurological problem

33. Development of "SWARM" as a model for high reliability, rapid problem solving, and institutional learning. | PSNet
    psnet.ahrq.gov/issue/development-swarm-model-high-reliability-rapid-problem-solving-and-institutional-learning
    November 16, 2022 - Commentary Development of "SWARM" as a model for high reliability, rapid problem … Development of "SWARM" as a Model for High Reliability, Rapid Problem Solving, and Institutional Learning … Development of "SWARM" as a Model for High Reliability, Rapid Problem Solving, and Institutional Learning

34. Overkill: An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it? | PSNet
    psnet.ahrq.gov/issue/overkill-avalanche-unnecessary-medical-care-harming-patients-physically-and-financially-what
    March 29, 2010 - A previous AHRQ WebM&M perspective explored overuse as a patient safety problem. … Patient Safety March 27, 2024 Overdiagnosis and overtreatment as a quality problem … April 13, 2016 The persistent problem of diagnostic error.

35. Rescue Improvement Conference Innovation Summary | PSNet
    psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
    September 23, 2024 - hospital staff to attend one-hour case review sessions, which focus on breakdowns in communication, problem … These two aspects of the innovation allow for multilevel problem-solving. … strengths of RIC go beyond a more traditional M&M model and include improvements to communication and problem-solving … This can be done by thoroughly describing the severity of the problem at the organization, and by leveraging … It may be helpful to frame the problem as a continuous quality improvement opportunity that builds on

36. Understanding the barriers to physician error reporting and disclosure: a systemic approach to a systemic problem. | PSNet
    psnet.ahrq.gov/issue/understanding-barriers-physician-error-reporting-and-disclosure-systemic-approach-systemic
    January 12, 2022 - Understanding the barriers to physician error reporting and disclosure: a systemic approach to a systemic problem … Understanding the barriers to physician error reporting and disclosure: a systemic approach to a systemic problem … Understanding the barriers to physician error reporting and disclosure: a systemic approach to a systemic problem

37. Physician burnout in the electronic health record era: are we ignoring the real cause? | PSNet
    psnet.ahrq.gov/issue/physician-burnout-electronic-health-record-era-are-we-ignoring-real-cause
    October 04, 2023 - Professional burnout is a pervasive problem among health care workers that can have serious effects … technology contributes to burnout, this commentary advocates for a broader approach to addressing the problem

38. Racial disparities in maternal mortality. | PSNet
    psnet.ahrq.gov/issue/racial-disparities-maternal-mortality
    June 17, 2020 - reviews weaknesses of this approach which include a lack of emphasis on state-level analysis of the problem … to address  system-level contributors  to the problem.

39. Invited article: Managing disruptive physician behavior: impact on staff relationships and patient care. | PSNet
    psnet.ahrq.gov/issue/invited-article-managing-disruptive-physician-behavior-impact-staff-relationships-and-patient
    February 03, 2010 - this area has investigated predictors of unprofessional actions and system-level solutions to the problem … September 24, 2010 Perspective How to Identify and Manage Problem … April 22, 2011 Perspective How to Identify and Manage Problem

40. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/865872/psn-pdf
    May 15, 2024 - Speaking up and taking action: psychological safety and joint problem-solving orientation in safety … Speaking up and taking action: psychological safety and joint problem-solving orientation in safety … https://psnet.ahrq.gov/issue/speaking-and-taking-action-psychological-safety-and-joint-problem-solving … This study explored the association of psychological safety and joint-problem- solving orientation ( … https://psnet.ahrq.gov/issue/speaking-and-taking-action-psychological-safety-and-joint-problem-solving-orientation-safety