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Showing results for "problem".

201. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43664/psn-pdf
     September 01, 2016 - Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational … Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational … https://psnet.ahrq.gov/issue/insights-problem-alarm-fatigue-physiologic-monitor-devices-comprehensive … https://psnet.ahrq.gov/issue/insights-problem-alarm-fatigue-physiologic-monitor-devices-comprehensive-observational-study … https://psnet.ahrq.gov/issue/insights-problem-alarm-fatigue-physiologic-monitor-devices-comprehensive-observational-study

202. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45320/psn-pdf
     January 01, 2017 - The problem with the '5 whys.' September 14, 2016 Card AJ. The problem with '5 whys'. … https://psnet.ahrq.gov/issue/problem-5-whys Investigation of incidents in complex systems can be hindered … https://psnet.ahrq.gov/issue/problem-5-whys https://psnet.ahrq.gov/issue/mind-gap-between-recommendation-and-implementation-principles-and-lessons-aftermath-incident

203. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44297/psn-pdf
     September 09, 2015 - The problem with checklists. September 9, 2015 Catchpole K, Russ S. The problem with checklists. … https://psnet.ahrq.gov/issue/problem-checklists Checklists, while popularly considered to address safety … https://psnet.ahrq.gov/issue/problem-checklists https://psnet.ahrq.gov/primer/checklists https://psnet.ahrq.gov

204. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46512/psn-pdf
     August 17, 2018 - The problem with using patient complaints for improvement. … The problem with using patient complaints for improvement. … https://psnet.ahrq.gov/issue/problem-using-patient-complaints-improvement Patient complaints can provide … https://psnet.ahrq.gov/issue/problem-using-patient-complaints-improvement https://psnet.ahrq.gov/issue

205. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45324/psn-pdf
     August 31, 2016 - The problem with medication reconciliation. August 31, 2016 Pevnick JM, Shane R, Schnipper JL. … The problem with medication reconciliation. … https://psnet.ahrq.gov/issue/problem-medication-reconciliation Medication reconciliation has demonstrated … https://psnet.ahrq.gov/issue/problem-medication-reconciliation https://psnet.ahrq.gov/primer/medication-reconciliation

206. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44701/psn-pdf
     June 07, 2016 - The problem with preventable deaths. June 7, 2016 Hogan H. The problem with preventable deaths. … https://psnet.ahrq.gov/issue/problem-preventable-deaths A key goal of patient safety improvement is … https://psnet.ahrq.gov/issue/problem-preventable-deaths https://psnet.ahrq.gov/issue/preventing-medical-injury

207. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44640/psn-pdf
     February 20, 2016 - The problem with Plan-Do-Study-Act cycles. February 20, 2016 Reed JE, Card AJ. … The problem with Plan-Do-Study-Act cycles. BMJ Qual Saf. 2016;25(3):147-52. … https://psnet.ahrq.gov/issue/problem-plan-do-study-act-cycles Rapid-cycle improvement methods have been … https://psnet.ahrq.gov/issue/problem-plan-do-study-act-cycles https://psnet.ahrq.gov/issue/improvement-guide-practical-approach-enhancing-organizational-performance

208. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34599/psn-pdf
     January 30, 2008 - Organizational Learning from Experience in High-Hazard Industries: Problem Investigations as Off-line … Paper 4359-02 https://psnet.ahrq.gov/issue/organizational-learning-experience-high-hazard-industries-problem … https://psnet.ahrq.gov/issue/organizational-learning-experience-high-hazard-industries-problem-investigations-line … https://psnet.ahrq.gov/issue/organizational-learning-experience-high-hazard-industries-problem-investigations-line

209. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45188/psn-pdf
     June 01, 2016 - Reporting and second-order problem solving can turn short-term fixes into long-term remedies. … https://psnet.ahrq.gov/issue/reporting-and-second-order-problem-solving-can-turn-short-term-fixes-long … https://psnet.ahrq.gov/issue/reporting-and-second-order-problem-solving-can-turn-short-term-fixes-long-term-remedies … https://psnet.ahrq.gov/issue/reporting-and-second-order-problem-solving-can-turn-short-term-fixes-long-term-remedies

210. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46813/psn-pdf
     March 14, 2018 - Our other prescription drug problem. March 14, 2018 Lembke A, Papac J, Humphreys K. … Our Other Prescription Drug Problem. … https://psnet.ahrq.gov/issue/our-other-prescription-drug-problem Unintended consequences can emerge … https://psnet.ahrq.gov/issue/our-other-prescription-drug-problem https://psnet.ahrq.gov/issue/identifying-unintended-consequences-quality-indicators-qualitative-study

211. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34720/psn-pdf
     April 21, 2011 - Human error and the problem of causality in analysis of accidents. April 21, 2011 Rasmussen J. … Human error and the problem of causality in analysis of accidents. … https://psnet.ahrq.gov/issue/human-error-and-problem-causality-analysis-accidents Reporting on a growing … https://psnet.ahrq.gov/issue/human-error-and-problem-causality-analysis-accidents

212. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45298/psn-pdf
     April 22, 2017 - The problem with root cause analysis. April 22, 2017 Peerally MF, Carr S, Waring J, et al. … The problem with root cause analysis. … https://psnet.ahrq.gov/issue/problem-root-cause-analysis Root cause analysis (RCA) is a strategy to … https://psnet.ahrq.gov/issue/problem-root-cause-analysis https://psnet.ahrq.gov/primer/root-cause-analysis

213. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44868/psn-pdf
     June 17, 2016 - Patient safety and the problem of many hands. June 17, 2016 Dixon-Woods M, Pronovost P. … Patient safety and the problem of many hands. … https://psnet.ahrq.gov/issue/patient-safety-and-problem-many-hands Although individual and organizational … https://psnet.ahrq.gov/issue/patient-safety-and-problem-many-hands https://psnet.ahrq.gov/issue/balancing-no-blame-accountability-patient-safety

214. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35374/psn-pdf
     January 02, 2017 - Intimidation: practitioners speak up about this unresolved problem. … Intimidation: Practitioners Speak Up About This Unresolved Problem. … https://psnet.ahrq.gov/issue/intimidation-practitioners-speak-about-unresolved-problem This survey, … https://psnet.ahrq.gov/issue/intimidation-practitioners-speak-about-unresolved-problem https://psnet.ahrq.gov

215. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837660/psn-pdf
     July 08, 2022 - The problem also needs to be highlighted in the problem list and discharge summary of the patient’s … Clearly highlight the problem in the medical record A reintubation or unexpected ICU admission due to … Affected patients usually remember that they had a significant problem during a previous procedure; … problem has been identified, it is paramount that the patient is informed about the nature of the problem … A multiple-hospital anaesthetic problem register: establishment of a regionally organized system for

216. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40390/psn-pdf
     February 03, 2015 - The $17.1 billion problem: the annual cost of measurable medical errors. … The $17.1 Billion Problem: The Annual Cost Of Measurable Medical Errors. … https://psnet.ahrq.gov/issue/171-billion-problem-annual-cost-measurable-medical-errors The Centers for … https://psnet.ahrq.gov/issue/171-billion-problem-annual-cost-measurable-medical-errors https://psnet.ahrq.gov

217. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/860049/psn-pdf
     January 04, 2024 - medical errors and, in one review of IT-related malpractice claims, was identified as a contributing problem … clinical information and evaluating that information against known illness scripts, often involves problem … Harnessing the power of problem representation can help us continue to think critically about our patients … Careful constructions of problem presentations, particularly in children with chronic medical conditions … The importance of early problem representation during case presentations.

218. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41796/psn-pdf
     January 18, 2013 - Retained surgical items: a problem yet to be solved. … Retained surgical items: a problem yet to be solved. … https://psnet.ahrq.gov/issue/retained-surgical-items-problem-yet-be-solved Stories of retained surgical … https://psnet.ahrq.gov/issue/retained-surgical-items-problem-yet-be-solved https://psnet.ahrq.gov/issue

219. Airway Obstruction during Anterior Cervical Spine Surgery | PSNet
     psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
     January 29, 2021 - the surgeon identified faulty positioning of the surgical retractor as the most likely cause of the problem … ventilator. 8 If ventilation remains inadequate after switching to the Ambu bag, the origin of the problem … An ultrasound, chest radiograph, or flexible bronchoscopy may help to diagnose the cause of the problem … Mental stress from the “blame game” makes it more difficult to solve the problem in a timely manner. … Trying to troubleshoot the equipment problem without using a bag-valve resuscitator may lead to hypoxemia

220. An Incomplete Anesthesia History Leads to Adverse Outcomes | PSNet
     psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
     January 29, 2021 - The problem also needs to be highlighted in the problem list and discharge summary of the patient’s medical … Clearly highlight the problem in the medical record A reintubation or unexpected ICU admission due … problem has been identified, it is paramount that the patient is informed about the nature of the problem … If the patient does not recognize the significance of the event, it is unlikely that the problem will … A multiple-hospital anaesthetic problem register: establishment of a regionally organized system for