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Total Results: 7,452 records

Showing results for "problem".

301. In Conversation With… Charles Vincent, MPhil, PhD | PSNet
     psnet.ahrq.gov/perspective/conversation-charles-vincent-mphil-phd
     July 10, 2024 - I think that's a major problem for us. … The second thing is, the biggest problem is that the reporting system is endlessly and still tediously … And that is still a major problem. … , which is the inclination of a single system to be top down and to articulate and operationalize a problem … I'm by no means against that, but I think the problem is that it becomes so massively complicated; it's

302. Remembering to learn: the overlooked role of remembrance in safety improvement. | PSNet
     psnet.ahrq.gov/issue/remembering-learn-overlooked-role-remembrance-safety-improvement
     February 28, 2024 - September 13, 2023 The problem with incident reporting. … November 6, 2015 The problem with checklists.

303. A case of mistaken identity: staff input on patient ID errors. | PSNet
     psnet.ahrq.gov/issue/case-mistaken-identity-staff-input-patient-id-errors
     March 27, 2024 - March 2, 2022 Indication alerts to improve problem list documentation. … January 29, 2020 The wicked problem of patient misidentification: how could the technological

304. Connecting perspectives on quality and safety: patient-level linkage of incident, adverse event and complaint data. | PSNet
     psnet.ahrq.gov/issue/connecting-perspectives-quality-and-safety-patient-level-linkage-incident-adverse-event-and
     April 28, 2021 - March 27, 2019 The problem with using patient complaints for improvement. … August 17, 2018 The problem with making Safety-II work in healthcare.

305. Complaints as Safety Surveillance | PSNet
     psnet.ahrq.gov/web-mm/complaints-safety-surveillance
     May 05, 2021 - A Different Kind of System Problem In our experience, most hospital-based practitioners admit that … they are aware of "problem" colleagues who attract multiple complaints, underperform, behave poorly, … doctors as another form of systems problem.( 6 ) That is, some doctors will perform poorly, but it is … of multiple complaints), remediation options should be chosen based on the nature of the underlying problem … Problem doctors: is there a system-level solution? Ann Intern Med. 2006;144:107-115.

306. In Conversation With… Sidney Dekker, MA, MSc, PhD | PSNet
     psnet.ahrq.gov/perspective/conversation-sidney-dekker-ma-msc-phd
     February 26, 2025 - The first is that the fundamental problem and tension of creating the just culture is this: We want to … A human error is not a personal problem; it's an organizational problem. … The problem obviously is that this tends of course to shut up sources of safety-critical information … How big a problem, in trying to calibrate the response, is it that the public often demands a pound of … SD : If we want to meaningfully, as a community, attack a problem like that weeding out and punishing

307. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46186/psn-pdf
     August 02, 2017 - A recent PSNet perspective discussed opioid overdose as a patient safety problem. … call-action-preventable-health-care-harm-public-health-crisis-and-patient-safety-requires https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem

308. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40816/psn-pdf
     March 21, 2017 - This study provides an approach for health care organizations to address the disturbingly common problem … psnet.ahrq.gov/issue/surveys-patient-safety-culture https://psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors

309. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46529/psn-pdf
     November 08, 2017 - psnet.ahrq.gov/issue/addressing-opioid-misuse https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem … https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem https://psnet.ahrq.gov/issue

310. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44127/psn-pdf
     September 28, 2017 - A previous AHRQ WebM&M perspective explored overuse as a patient safety problem. … diagnosing-overdiagnosis-conceptual-challenges-and-suggested-solutions https://psnet.ahrq.gov/perspective/overuse-patient-safety-problem

311. Inappropriate medication in a national sample of US elderly patients receiving home health care. | PSNet
     psnet.ahrq.gov/issue/inappropriate-medication-national-sample-us-elderly-patients-receiving-home-health-care
     September 09, 2020 - August 4, 2021 Retained surgical items: a problem yet to be solved. … January 18, 2013 Indication alerts to improve problem list documentation.

312. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49622/psn-pdf
     March 01, 2011 - not work as needed, and so the user "plays games" with the system to defeat it.(3) This is a serious problem … own notifications who else was notified, they too would have had a chance to catch and correct the problem … This problem of lack of visibility is common in health information technology (IT). … Or as in this case, it may simply be that the patient catches the problem before harm occurs. … Challenges and problem-solving strategies during medication management: a study of a pediatric hospital

313. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37750/psn-pdf
     May 07, 2008 - this area has investigated predictors of unprofessional actions and system-level solutions to the problem … /disciplinary-action-medical-boards-and-prior-behavior-medical-schools https://psnet.ahrq.gov/issue/problem-doctors-there-system-level-solution

314. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46823/psn-pdf
     August 20, 2018 - A previous PSNet perspective discussed how to identify and manage problem behaviors. … primer/adverse-events-near-misses-and-errors https://psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors

315. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47283/psn-pdf
     January 27, 2019 - four-states-robust-prescription-drug-monitoring-programs-reduced-opioid-dosages https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem … https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem

316. Alert Fatigue | PSNet
     psnet.ahrq.gov/primer/alert-fatigue
     March 15, 2025 - The problem is that clinicians then ignore both the bothersome, clinically meaningless alarms and the … require use of the principles of human factors engineering as well as those of informatics, as the problem … In solving the problem of alert fatigue, health care will need to look to examples from other industries … March 29, 2023 Applying human factors engineering to address the telemetry alarm problem

317. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33642/psn-pdf
     November 01, 2006 - Initially, I was interested in the classical problems in psychology (memory, attention, thinking, problem … They analyze the problem, they analyze the possible solutions, and they design a solution. … Now anybody who designs anything has a problem of understanding the thing they're designing too well … So part of the problem is not seeing it as a system, that things have to work in context. … The problem is we tend to deny it.

318. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40213/psn-pdf
     February 16, 2011 - trigger tools to MEDMARX, limitations in whether these systems provide a true representation of the problem … medmarxr https://psnet.ahrq.gov/issue/incident-reporting-system-does-not-detect-adverse-drug-events-problem-quality-improvement

319. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47178/psn-pdf
     July 10, 2018 - A past PSNet perspective highlighted overuse as a patient safety problem. … possible-net-harms-breast-cancer-screening-updated-modelling-forrest-report https://psnet.ahrq.gov/perspective/overuse-patient-safety-problem

320. Follow-up of markedly elevated serum potassium results in the ambulatory setting: implications for patient safety. | PSNet
     psnet.ahrq.gov/issue/follow-markedly-elevated-serum-potassium-results-ambulatory-setting-implications-patient
     September 29, 2021 - September 1, 2016 The problem with medication reconciliation. … September 17, 2014 Drug-induced hypoglycaemia--new insight into an old problem.