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Total Results: 1,785 records

Showing results for "problem".

221. Operationalizing Patient Safety at Academic Medical Centers | PSNet
     psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
     August 01, 2010 - bring an extra nurse in on the day shift to free up the nurses to do some of these observations and problem … That's the approach we've taken—really putting the problem in the hands of the people engaged in doing … We coupled this foundation with empowering them with a new set of tools and real-time, problem-solving … We find all these defects that we can begin to codify and do the same type of real-time problem solving … The problem at the start is that the number of defects is overwhelming.

222. In Conversation With… Mark Graban, MS, MBA | PSNet
     psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba
     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.

223. Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care | PSNet
     psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually-supportive-partners-transformation-health-care
     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.

224. Communication With Consultants | PSNet
     psnet.ahrq.gov/web-mm/communication-consultants
     October 01, 2018 - Cohn, MD Communication failures are a major safety problem in health care. … a different response than one asking for specific advice on the management of a particular medical problem … leukocytosis in a previously healthy pregnant patient, and the hematology consultant approached the problem

225. Copy and Paste | PSNet
     psnet.ahrq.gov/web-mm/copy-and-paste
     December 10, 2014 - developed and validated an algorithm for detecting such copying.( 12 ) A detailed instance of this problem … The solution to this problem, of course, should be based on the solution to all errors of omission in … 2005 Perspective The Soil, Not the Seed: The Real Problem

226. Which End Is Which? | PSNet
     psnet.ahrq.gov/web-mm/which-end-which
     February 09, 2011 - The core problem here consisted of failure to identify the appropriate limb of colon to bring up for … The problem with any laparoscopic surgery is that normal cues for anatomic identification are easily … using Gastrografin through the colostomy could have been performed to confirm or rule out an anatomical problem

227. Technology, cognition and error. | PSNet
     psnet.ahrq.gov/issue/technology-cognition-and-error
     September 04, 2024 - Technology as a Tool for Improving Patient Safety March 29, 2023 The wicked problem

228. The Economics of Diagnostic Safety. | PSNet
     psnet.ahrq.gov/issue/economics-diagnostic-safety
     July 28, 2021 - Related Resources Addressing racial and ethnic bias in pulse oximeters—a wicked problem

229. In Conversation with Eric Thomas about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement | PSNet
     psnet.ahrq.gov/perspective/conversation-eric-thomas-about-zero-harm-striving-reduce-preventable-harms-point
     September 24, 2024 - The other problem that happens when you have a goal that is hard to meet is that people on the front … Another problem I have with zero harm is that setting idealized goals is not how organizations become … This is another problem with zero harm: some things can be zero, and others cannot. … management principle espoused by Jim Collins and Jerry Porras, in which setting a lofty goal solves the problem … amount of effort expended in the resource scarce environment of hospital administration suggests one problem

230. Near Miss With Neonate | PSNet
     psnet.ahrq.gov/web-mm/near-miss-neonate
     August 15, 2018 - One way to support clear communication during transfer of care is to use patient problem lists to document … For health systems that are still using paper records, a current problem list placed at the front of … the time of admission, might have prevented the error.( 12-14 ) Take-Home Points Use patient problem

231. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45023/psn-pdf
     April 17, 2018 - One chapter focuses on the use of root cause problem- solving and error prevention.

232. Millions of people used tainted breathing machines. The FDA failed to use its power to protect them. | PSNet
     psnet.ahrq.gov/issue/millions-people-used-tainted-breathing-machines-fda-failed-use-its-power-protect-them
     June 28, 2023 - Related Resources Addressing racial and ethnic bias in pulse oximeters—a wicked problem

233. Failure to Report | PSNet
     psnet.ahrq.gov/web-mm/failure-report
     July 01, 2008 - Trusting that "the process will not fail" or "a problem will not happen to me" is a latent condition … perceived attitudes that management would take no notice and was not likely to do anything about the problem … Problem Doctors: A Conspiracy of Silence. Amsterdam, NLD: IOS Press; 1997. 8. Leven L, Ashton JR. … Author(s) Perspective The Soil, Not the Seed: The Real Problem

234. Health Care Worker Presenteeism: A Challenge for Patient Safety | PSNet
     psnet.ahrq.gov/perspective/health-care-worker-presenteeism-challenge-patient-safety
     November 03, 2015 - Presenteeism Is Common and Dangerous Working while ill, known as presenteeism, is a particularly pervasive problem … Reducing it will require attention to all drivers of the problem: logistics, culture, and knowledge. … Perspective Health Care–Acquired Urinary Tract Infection: The Problem

235. Diagnostic Excellence. | PSNet
     psnet.ahrq.gov/issue/diagnostic-excellence-0
     December 08, 2021 - April 4, 2018 Diagnostic Error: Is Overconfidence the Problem.

236. What medications does your patient take? Enhancing medication safety in the outpatient setting. | PSNet
     psnet.ahrq.gov/issue/what-medications-does-your-patient-take-enhancing-medication-safety-outpatient-setting
     January 08, 2020 - April 29, 2018 The problem with medication reconciliation.

237. In Conversation with...Dean Schillinger, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-withdean-schillinger-md
     March 01, 2009 - The most salient and consistent problem I experience as a provider is the issue of communication barriers … of us in the field of health literacy have tried very hard to describe health literacy as a systems problem … Well, it cannot be that 50% of individuals in the United States have a problem. … Given the prevalence of the problem, particularly if one is working in a public hospital, I don't advocate … On the other hand, we could see the health IT revolution as a solution to the health literacy problem

238. The Role of Health Literacy in Patient Safety | PSNet
     psnet.ahrq.gov/perspective/role-health-literacy-patient-safety
     March 22, 2009 - The most salient and consistent problem I experience as a provider is the issue of communication barriers … of us in the field of health literacy have tried very hard to describe health literacy as a systems problem … Well, it cannot be that 50% of individuals in the United States have a problem. … Given the prevalence of the problem, particularly if one is working in a public hospital, I don't advocate … On the other hand, we could see the health IT revolution as a solution to the health literacy problem

239. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33606/psn-pdf
     December 15, 2024 - This Primer will describe the nature of the opioid epidemic as a patient safety problem, discuss the … trends-statistics/overdose-death-rates#Fig3 https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem

240. The effects of physical environments in medical wards on medication communication processes affecting patient safety. | PSNet
     psnet.ahrq.gov/issue/effects-physical-environments-medical-wards-medication-communication-processes-affecting
     November 17, 2021 - March 13, 2013 A multiple-drawer medication layout problem in automated dispensing cabinets