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psnet.ahrq.gov/primer/missed-nursing-care
September 15, 2024 - First, missed nursing care is primarily a problem of time pressure and competing demands, and adequate … Cultivating cross-monitoring and cooperative problem-solving skills among staff may decrease the frequency
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psnet.ahrq.gov/node/44513/psn-pdf
September 23, 2015 - and far more resources, at the practice, policy, and research levels to address this pressing safety problem
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psnet.ahrq.gov/issue/error-and-uncertainty-diagnostic-radiology
December 18, 2019 - November 18, 2015
Medical Problem Solving: An Analysis of Clinical Reasoning.
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psnet.ahrq.gov/issue/future-directions-diagnostic-decision-support
February 25, 2019 - Resources From the Same Author(s)
The opioid crisis: can improving diagnosis help solve the problem
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psnet.ahrq.gov/issue/doctor-uses-pre-flight-checklist
May 22, 2019 - April 5, 2006
IV potassium given epidurally: getting to the "route" of the problem.
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psnet.ahrq.gov/issue/engaging-patients-safety-partners-guide-reducing-errors-and-improving-satisfaction
May 20, 2019 - October 29, 2013
Medical Problem Solving: An Analysis of Clinical Reasoning.
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psnet.ahrq.gov/issue/hospital-compare
May 26, 2021 - May 18, 2018
The $17.1 billion problem: the annual cost of measurable medical errors.
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psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
August 21, 2016 - Problem of many hands
Many actors, both within and outside the health care organization, may be implicated … The problem with root cause analysis. BMJ Qual Saf. 2017;26:417-422. … Focusing more specifically on problems with RCA tools and techniques, Card described " the problem with
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psnet.ahrq.gov/web-mm/right-patient-wrong-sample
June 01, 2004 - difficult to implement, but they are likely to be the only truly robust solutions to the pervasive problem … provider to order the correct test ___ Incorrect specimen container (e.g., blood tube) or order of draw problem … of fluid contamination ___ Specimen suboptimal, ruined, or inadequate for other reason ___ Transport problem … Incorrect results reported for other reasons ___ Laboratory information system or other information systems problem
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psnet.ahrq.gov/issue/nurses-role-medication-safety
June 26, 2024 - January 4, 2012
View More
Related Resources
The wicked problem
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psnet.ahrq.gov/issue/early-warnings-weak-signals-and-learning-healthcare-disasters
February 28, 2024 - July 21, 2017
The problem with incident reporting.
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psnet.ahrq.gov/issue/medical-diagnoses-commonly-associated-pediatric-malpractice-lawsuits-united-states
November 16, 2022 - June 12, 2019
Laney's story: the problem of delayed diagnosis of pediatric stroke.
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psnet.ahrq.gov/web-mm/double-dosing-rules
February 03, 2010 - This is especially apparent when the strategic decision prescribes a solution that shifts the problem … Too often the individuals who "solved" the original problem are different from those who ultimately inherit … the new problem.
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psnet.ahrq.gov/web-mm/medication-reconciliation-victory-after-avoidable-error
April 01, 2015 - States annually.( 2 ) Furthermore, potentially inappropriate medication (PIM) use is a significant problem … First, the continued use of PIM in older adults remains a problem and dramatically increases the likelihood … of developing a drug-related problem.( 5 ) Second, medication reconciliation can identify potential
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psnet.ahrq.gov/issue/my-patient-almost-died-mistake-i-made-i-apologized-and-it-changed-my-life
October 23, 2019 - December 11, 2019
A doctor gave me an inept diagnosis for a neurological problem.
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psnet.ahrq.gov/issue/burnout-and-resilience-and-quality-and-safety-programs-obstetrics-and-gynecology
May 29, 2019 - July 26, 2017
The other big drug problem: older people taking too many pills.
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psnet.ahrq.gov/issue/profiles-patient-safety-authority-gradients-medical-error
August 28, 2019 - View More
Related Resources
Implicit bias in stroke care: a recurring old problem
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psnet.ahrq.gov/issue/artificial-intelligence-makes-bad-medicine-even-worse
November 25, 2020 - May 5, 2021
A doctor gave me an inept diagnosis for a neurological problem.
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psnet.ahrq.gov/issue/how-useful-are-medication-patient-information-leaflets-older-adults-content-readability-and
November 11, 2020 - March 27, 2019
The problem with medication reconciliation.
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psnet.ahrq.gov/node/33579/psn-pdf
September 15, 2024 - Attentional behavior is characterized by conscious thought, analysis, and
planning, as occurs in active problem … error, and the availability of resources (financial,
time, and personnel) available to address the problem