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psnet.ahrq.gov/issue/intimidation-practitioners-speak-about-unresolved-problem
September 26, 2017 - Study
Intimidation: practitioners speak up about this unresolved problem. … Intimidation: Practitioners Speak Up About This Unresolved Problem. … Intimidation: Practitioners Speak Up About This Unresolved Problem.
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psnet.ahrq.gov/issue/when-good-doctors-go-bad-systems-problem
November 02, 2014 - Commentary
When good doctors go bad: a systems problem. … When good doctors go bad: a systems problem. Ann Surg. 2006;244(5):649-652. … When good doctors go bad: a systems problem. Ann Surg. 2006;244(5):649-652. … December 23, 2008
Problem doctors: is there a system-level solution?
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psnet.ahrq.gov/issue/adverse-outpatient-drug-events-problem-and-opportunity
April 12, 2011 - Commentary
Adverse outpatient drug events—a problem and an opportunity. … Adverse outpatient drug events--a problem and an opportunity. N Engl J Med. 2003;348(16):1587-9. … Adverse outpatient drug events--a problem and an opportunity. … September 1, 2016
The problem with medication reconciliation.
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psnet.ahrq.gov/issue/retained-surgical-items-problem-yet-be-solved
September 24, 2014 - Study
Retained surgical items: a problem yet to be solved. … Retained surgical items: a problem yet to be solved. … Retained surgical items: a problem yet to be solved. … December 21, 2014
The recurring problem of retained swabs and instruments.
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psnet.ahrq.gov/issue/human-error-and-problem-causality-analysis-accidents
August 25, 2021 - Commentary
Classic
Human error and the problem of causality … Human error and the problem of causality in analysis of accidents. … Human error and the problem of causality in analysis of accidents.
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psnet.ahrq.gov/issue/iv-potassium-given-epidurally-getting-route-problem
April 20, 2022 - Newspaper/Magazine Article
IV potassium given epidurally: getting to the "route" of the problem … Citation Text:
IV potassium given epidurally: getting to the "route" of the problem. … Citation
Citation Text:
IV potassium given epidurally: getting to the "route" of the problem
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psnet.ahrq.gov/issue/problems-detecting-medication-errors-hospitals
February 01, 2012 - method for estimating medication errors, and that previous efforts to assess the prevalence of the problem
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psnet.ahrq.gov/issue/patient-falls-operating-room-why-still-problem-2024
May 08, 2024 - Commentary
Patient falls in the operating room: why is this still a problem in 2024 … Patient falls in the operating room: why is this still a problem in 2024? … Patient falls in the operating room: why is this still a problem in 2024?
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psnet.ahrq.gov/issue/problem-withusing-stories-source-evidence-and-learning
June 19, 2018 - Commentary
The problem with…using stories as a source of evidence and learning. … The problem with … using stories as a source of evidence and learning. … The problem with … using stories as a source of evidence and learning. … Related Resources From the Same Author(s)
Overdiagnosis and overtreatment as a quality problem
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psnet.ahrq.gov/issue/171-billion-problem-annual-cost-measurable-medical-errors
May 26, 2021 - Study
Classic
The $17.1 billion problem: the annual cost … The $17.1 Billion Problem: The Annual Cost Of Measurable Medical Errors. … The $17.1 Billion Problem: The Annual Cost Of Measurable Medical Errors.
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psnet.ahrq.gov/issue/what-can-physicians-do-help-curb-opioid-crisis
December 18, 2019 - The persistent problem of opioid-related harm calls for changes in pain management practices and system … An Annual Perspective discussed the opioid crisis as a patient safety problem. … July 2, 2019
The opioid crisis: can improving diagnosis help solve the problem?
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psnet.ahrq.gov/issue/patient-safety-public-health
July 19, 2023 - Medical error has been recognized as a serious problem in the United States. … July 19, 2023
The problem with the '5 whys.' … September 14, 2016
The problem with Plan-Do-Study-Act cycles.
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psnet.ahrq.gov/issue/strategies-learning-failure
September 25, 2024 - detection and reporting of problems by frontline staff, and promote experimentation and creative problem-solving … September 25, 2024
Speaking up and taking action: psychological safety and joint problem-solving … March 8, 2017
Development of "SWARM" as a model for high reliability, rapid problem solving
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psnet.ahrq.gov/issue/laneys-story-problem-delayed-diagnosis-pediatric-stroke
April 24, 2018 - Commentary
Laney's story: the problem of delayed diagnosis of pediatric stroke. … Laney's Story: The Problem of Delayed Diagnosis of Pediatric Stroke. … Laney's Story: The Problem of Delayed Diagnosis of Pediatric Stroke.
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psnet.ahrq.gov/issue/overdiagnosis-primary-care-framing-problem-and-finding-solutions
November 01, 2017 - Emerging Classic
Overdiagnosis in primary care: framing the problem … Overdiagnosis in primary care: framing the problem and finding solutions. … Overdiagnosis in primary care: framing the problem and finding solutions.
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psnet.ahrq.gov/issue/identifying-adverse-events-reflections-imperfect-gold-standard-after-20-years-patient-safety
September 09, 2015 - The authors note that these approaches have served to demonstrate the scope of the patient safety problem … March 27, 2019
The problem with using patient complaints for improvement. … September 18, 2024
The problem with 'never events'. … August 7, 2024
Patient falls in the operating room: why is this still a problem in 2024
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psnet.ahrq.gov/issue/multiple-drawer-medication-layout-problem-automated-dispensing-cabinets
December 21, 2017 - Study
A multiple-drawer medication layout problem in automated dispensing cabinets … A multiple-drawer medication layout problem in automated dispensing cabinets. … A multiple-drawer medication layout problem in automated dispensing cabinets.
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psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
November 01, 2008 - Health Care–Acquired Urinary Tract Infection: The Problem and Solutions
Lindsay E. … Health Care–Acquired Urinary Tract Infection: The Problem and Solutions. PSNet [internet]. … Health Care–Acquired Urinary Tract Infection: The Problem and Solutions. PSNet [internet]. … So it's unclear which one is more likely to be a problem. … What do you think of the accreditation and regulatory approach to this problem?
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psnet.ahrq.gov/issue/she-was-headed-locked-psych-ward-then-er-doctor-made-startling-discovery
March 03, 2021 - This news story illustrates the problem of omissions due to potential stigma associated with patient … December 14, 2016
The other big drug problem: older people taking too many pills. … November 4, 2020
A doctor gave me an inept diagnosis for a neurological problem.
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psnet.ahrq.gov/issue/drug-related-problem-outcomes-and-program-satisfaction-comprehensive-brown-bag-medication
September 23, 2020 - Review
Drug-related-problem outcomes and program satisfaction from a comprehensive … Drug-Related-Problem Outcomes and Program Satisfaction from a Comprehensive Brown Bag Medication Review … Drug-Related-Problem Outcomes and Program Satisfaction from a Comprehensive Brown Bag Medication Review … February 12, 2020
The problem with medication reconciliation.