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Showing results for "problem".

361. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33677/psn-pdf
     November 01, 2008 - Health Care–Acquired Urinary Tract Infection: The Problem and Solutions November 1, 2008 Nicolle LE … Health Care–Acquired Urinary Tract Infection: The Problem and Solutions. PSNet [internet]. 2008. … https://psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions … Moreover, this particular safety problem is largely attributable to an invasive health care intervention … Thus, cUTI is a technological problem attributed to the ability of microorganisms to produce biofilm.

362. A Costly Colonoscopy Leads to a Delay in Diagnosis | PSNet
     psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
     September 01, 2014 - Christopher Moriates, MD In 2016, 63 million adults aged 19 to 64 (34%) reported having a cost-related problem … scores and more rehospitalizations.( 3 ) In addition, cost-related medication nonadherence is a common problem … when the primary care provider finally called the insurance company, he was able to quickly resolve a problem … Clinicians and health care systems should address this problem systematically, just as they do with other … Same Author(s) Perspective Overuse as a Patient Safety Problem

363. Dropping the Ball Despite an Integrated EMR | PSNet
     psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr
     January 07, 2015 - 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

364. A multicenter collaborative effort to reduce preventable patient harm due to retained surgical items. | PSNet
     psnet.ahrq.gov/issue/multicenter-collaborative-effort-reduce-preventable-patient-harm-due-retained-surgical-items
     March 20, 2019 - December 15, 2024 Patient falls in the operating room: why is this still a problem … September 21, 2022 Crisis recovery in surgery: error management and problem solving in

365. Safety cases for digital health innovations: can they work? | PSNet
     psnet.ahrq.gov/issue/safety-cases-digital-health-innovations-can-they-work
     April 13, 2022 - Download Citation Related Resources From the Same Author(s) The problem … Related Resources Addressing racial and ethnic bias in pulse oximeters—a wicked problem

366. Learning from morbidity and mortality conferences: focus and sustainability of lessons for patient care. | PSNet
     psnet.ahrq.gov/issue/learning-morbidity-and-mortality-conferences-focus-and-sustainability-lessons-patient-care
     April 13, 2022 - Download Citation Related Resources From the Same Author(s) The problem … March 27, 2019 The problem with using patient complaints for improvement.

367. Considering chance in quality and safety performance measures: an analysis of performance reports by boards in English NHS trusts. | PSNet
     psnet.ahrq.gov/issue/considering-chance-quality-and-safety-performance-measures-analysis-performance-reports
     October 27, 2021 - The problem with red, amber, green: the need to avoid distraction by random variation in organisational … The problem with red, amber, green: the need to avoid distraction by random variation in organisational

368. Distractions in the operating room: a survey of the healthcare team. | PSNet
     psnet.ahrq.gov/issue/distractions-operating-room-survey-healthcare-team
     November 16, 2022 - January 8, 2025 Patient falls in the operating room: why is this still a problem in 2024 … November 30, 2022 Crisis recovery in surgery: error management and problem solving in

369. Changes in default alarm settings and standard in-service are insufficient to improve alarm fatigue in an intensive care unit: a pilot project. | PSNet
     psnet.ahrq.gov/issue/changes-default-alarm-settings-and-standard-service-are-insufficient-improve-alarm-fatigue
     May 29, 2019 - August 31, 2016 Applying human factors engineering to address the telemetry alarm problem … September 1, 2016 Insights into the problem of alarm fatigue with physiologic monitor

370. Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis. | PSNet
     psnet.ahrq.gov/issue/association-between-concurrent-use-prescription-opioids-and-benzodiazepines-and-overdose
     November 16, 2022 - June 16, 2019 The opioid crisis: can improving diagnosis help solve the problem? … 2017 Perspective Opioid Overdose as a Patient Safety Problem

371. Disseminating innovations in health care. | PSNet
     psnet.ahrq.gov/issue/disseminating-innovations-health-care
     August 04, 2021 - Fall; Part 2: Cursed By Knowledge: Building a Culture of Psychological Safety; and Part 3: The Not-My-Problem … Problem.

372. Quality improvement as a primary approach to change in healthcare: a precarious, self-limiting choice? | PSNet
     psnet.ahrq.gov/issue/quality-improvement-primary-approach-change-healthcare-precarious-self-limiting-choice
     June 08, 2022 - January 8, 2020 Overdiagnosis and overtreatment as a quality problem: insights from healthcare … June 19, 2018 The problem with…using stories as a source of evidence and learning.

373. Examining medication ordering errors using AHRQ Network of Patient Safety Databases. | PSNet
     psnet.ahrq.gov/issue/examining-medication-ordering-errors-using-ahrq-network-patient-safety-databases
     November 30, 2022 - November 30, 2022 Indication alerts to improve problem list documentation. … April 27, 2022 Indication alerts to improve problem list documentation.

374. PowerPoint Presentation (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.362_slideshow.ppt
     December 01, 2015 - 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 … Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational … Excessive Alarms The biggest harm from alert fatigue is that a patient develops a life-threatening problem … 22 Take-Home Points Alarms should never be completely silenced; clinical staff should instead problem-solve

375. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33807/psn-pdf
     May 01, 2016 - That provoked me to contact our nursing administrator at UCSF to ask, "Do you think we have the same problem … RW: When you first began investigating this, did you have a theory as to what the problem was, and did … highlight some of the key statistics that gave you an understanding of the breadth and depth of the problem … RW: That's just such a wonderful story that captures the essence of the problem. … BD: Alarm fatigue is probably a much bigger problem on a general medical floor than in the ICU.

376. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836879/psn-pdf
     April 27, 2022 - truly shocked to discover the extent of medical error and, to me, the then-inconceivable fact that a problem … And part of the problem is that the hospitals I admire that have truly gone toward zero harm in terms … I wrote in the Health Affairs blog in 2010 that the problem is due to the three I’s: invisibility, inertia … How many people like that, if they have a problem with their care, turn to Twitter? … Now the problem has salience. That’s just human nature—the squeaky wheel gets the grease.

377. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33778/psn-pdf
     March 01, 2015 - Epidemiology: Scope of the Problem https://psnet.ahrq.gov/perspective/diagnostic-errors https://psnet.ahrq.gov … Causes of the Problem As noted at the outset, something about diagnostic errors strikes many clinicians … reflecting individual performance, with less obvious roles for a systems approach to addressing the problem … organizational problems such as poor policies and inadequate staffing and equipment, making clear that the problem … Addressing the Problem As intellectually appealing as cognitive debiasing may be, addressing systems

378. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33728/psn-pdf
     May 01, 2012 - emergent stop order for the sedative, either of which triggers would indicate that there might be a problem … The problem is our reporting systems are not necessarily well set up for this transition. … The problem is you can spend an infinite number of resources on building these reporting systems. … I view this as a multi-decade problem to solve, much as it was for the aviation industry. … , and then communicating with the health care team to say, "Have you seen this problem?

379. Changes in prescription and over-the-counter medication and dietary supplement use among older adults in the United States, 2005 vs 2011. | PSNet
     psnet.ahrq.gov/issue/changes-prescription-and-over-counter-medication-and-dietary-supplement-use-among-older
     May 06, 2020 - 2019 Perspective Opioid Overdose as a Patient Safety Problem … View More Related Resources Medication Overload: America's Other Drug Problem

380. Medication errors with the dosing of insulin: problems across the continuum. | PSNet
     psnet.ahrq.gov/issue/medication-errors-dosing-insulin-problems-across-continuum
     March 14, 2012 - Government Resource Medication errors with the dosing of insulin: problems across the continuum. Citation Text: Medication errors with the dosing of insulin: problems across the continuum. PA-PSRS Patient Saf Advis. March 2010;7:9-17. Copy Citation Save Save to …