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Total Results: 7,452 records

Showing results for "problem".

341. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/855058/psn-pdf
     October 31, 2023 - It’s not as simple as one level versus another, but rather it’s a multilevel problem. … to safely report incidents of violence, which makes it hard to understand the real magnitude of the problem … Jones: I think when addressing the problem of workplace violence, focusing on a provider or organizational … It really is a multilayered problem that starts with policymakers, payers, and providers, including … It’s a larger, systemic problem, it’s an organizational problem, and then it’s really a problem of public

342. Hospital ward incidents through the eyes of nurses – a thick description on the appeal and deadlock of incident reporting systems. | PSNet
     psnet.ahrq.gov/issue/hospital-ward-incidents-through-eyes-nurses-thick-description-appeal-and-deadlock-incident
     November 15, 2023 - February 20, 2019 The problem with using patient complaints for improvement. … August 17, 2018 The problem with making Safety-II work in healthcare.

343. What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety | PSNet
     psnet.ahrq.gov/perspective/what-weve-learned-about-leveraging-leadership-and-culture-affect-change-and-improve
     March 01, 2017 - Culture change inevitably occurs slowly, through cycles of action and interpretation.( 8 ) Problem solving … A focus on problem solving also reinforces the learning orientation that is core to a culture of safety … while building problem-solving capacity. … Often considered "the problem," resistance may be more productively and accurately viewed as the key … 1, 2013 Perspective How to Identify and Manage Problem

344. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49769/psn-pdf
     September 01, 2016 - 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, or … 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.

345. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42639/psn-pdf
     November 08, 2013 - tolerated in health care despite the safety risks, this innovative program demonstrates that this problem … disruptive-and-unprofessional-behavior https://psnet.ahrq.gov/issue/patient-complaints-and-malpractice-risk https://psnet.ahrq.gov/issue/problem-doctors-there-system-level-solution

346. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40024/psn-pdf
     December 21, 2014 - This study examined the problem of retained foreign bodies in pediatric surgery, using cases identified … Despite the persistence of this problem, controversy remains around how to prevent such errors.

347. The global burden of diagnostic errors in primary care. | PSNet
     psnet.ahrq.gov/issue/global-burden-diagnostic-errors-primary-care
     May 25, 2022 - December 2, 2020 Overdiagnosis in primary care: framing the problem and finding solutions … November 17, 2010 Quality of medication use in primary care—mapping the problem, working

348. How one medical checkup can snowball into a ‘cascade’ of tests, causing more harm than good. | PSNet
     psnet.ahrq.gov/issue/how-one-medical-checkup-can-snowball-cascade-tests-causing-more-harm-good
     February 03, 2021 - October 23, 2019 A doctor gave me an inept diagnosis for a neurological problem. … February 6, 2019 Overdiagnosis in primary care: framing the problem and finding solutions

349. Patient safety professionals as the third victims of adverse events. | PSNet
     psnet.ahrq.gov/issue/patient-safety-professionals-third-victims-adverse-events
     July 07, 2021 - July 7, 2021 The problem with Plan-Do-Study-Act cycles. … July 19, 2023 The problem with the '5 whys.'

350. Surgical count process for prevention of retained surgical items: an integrative review. | PSNet
     psnet.ahrq.gov/issue/surgical-count-process-prevention-retained-surgical-items-integrative-review
     March 09, 2022 - May 26, 2016 The recurring problem of retained swabs and instruments. … February 20, 2013 Retained surgical items: a problem yet to be solved.

351. Using the patient safety huddle as a tool for high reliability. | PSNet
     psnet.ahrq.gov/issue/using-patient-safety-huddle-tool-high-reliability
     March 01, 2023 - Fall; Part 2: Cursed By Knowledge: Building a Culture of Psychological Safety; and Part 3: The Not-My-Problem … Problem.

352. Effect of pharmacists on medication errors in an emergency department. | PSNet
     psnet.ahrq.gov/issue/effect-pharmacists-medication-errors-emergency-department
     September 23, 2020 - November 30, 2011 Drug-related-problem outcomes and program satisfaction from a comprehensive … July 1, 2017 Indication alerts to improve problem list documentation.

353. Alarm system management: evidence-based guidance encouraging direct measurement of informativeness to improve alarm response. | PSNet
     psnet.ahrq.gov/issue/alarm-system-management-evidence-based-guidance-encouraging-direct-measurement
     August 11, 2021 - the Same Author(s) Applying human factors engineering to address the telemetry alarm problem … September 24, 2014 Retained surgical items: a problem yet to be solved.

354. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33825/psn-pdf
     January 01, 2017 - 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 … www.ncbi.nlm.nih.gov/pubmed/27340202 http://www.ncbi.nlm.nih.gov/pubmed/27340202 https://psnet.ahrq.gov/issue/problem … -5-whys https://psnet.ahrq.gov/issue/problem-5-whys https://psnet.ahrq.gov/issue/systems-approach-medicine-controversy-and-misconceptions

355. In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring | PSNet
     psnet.ahrq.gov/perspective/conversation-susan-mcgrath-phd-and-george-blike-md-about-surveillance-monitoring
     April 26, 2023 - He came to the team and said, “I have this problem in the inpatient setting, let’s do something about … Another aspect of the alarm problem is distraction. … Finally, there’s the literature on alarm fatigue, which gets confused with the alarm problem, because … You’re trying to address the problem of severe and sustained events. … monitoring on general care units is the alarm problem .

356. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45113/psn-pdf
     May 11, 2016 - controversial, the authors do highlight the lack of accurate strategies for measuring safety events—a problem … avoidability-hospital-deaths-and-association-hospital-wide-mortality-ratios-retrospective https://psnet.ahrq.gov/issue/problem-preventable-deaths

357. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43539/psn-pdf
     March 26, 2015 - Other PSIs demonstrated the opposite problem—potential for over-reporting due to a high false- positive … interpretation by coders due to the substantially larger number of diagnoses included in ICD-10 (a problem

358. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33698/psn-pdf
     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.

359. Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units | PSNet
     psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-acute-hospital-care-units
     April 26, 2023 - monitoring on general care units is the alarm problem . … He came to the team and said, “I have this problem in the inpatient setting, let’s do something about … Another aspect of the alarm problem is distraction. … Finally, there’s the literature on alarm fatigue, which gets confused with the alarm problem, because … You’re trying to address the problem of severe and sustained events.

360. Performance variability in perioperative sentinel events: report on a nationwide data set. | PSNet
     psnet.ahrq.gov/issue/performance-variability-perioperative-sentinel-events-report-nationwide-data-set
     November 04, 2020 - November 30, 2022 Crisis recovery in surgery: error management and problem solving in … August 12, 2020 Retained surgical items: a problem yet to be solved.