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Showing results for "problem".

41. Clinicians' expectations of the benefits and harms of treatments, screening, and tests: a systematic review. | PSNet
    psnet.ahrq.gov/issue/clinicians-expectations-benefits-and-harms-treatments-screening-and-tests-systematic-review
    May 05, 2021 - Overuse of medical care represents a significant patient safety problem , with the potential for serious … October 10, 2018 Overdiagnosis in primary care: framing the problem and finding solutions

42. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. | PSNet
    psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-complications-after-gastric-bypass-surgery
    September 25, 2019 - to be solved at one point in time, rather than a recurring and evolving problem that is influenced by … From a psychological standpoint, problem representation can be conceived in two ways. 11 First, and … The second way to conceive of problem representation is as an individual’s mental representation of a … The importance of early problem representation during case presentations. … Reasoning on rounds: summary statement or problem representation?

43. Incident reporting system does not detect adverse drug events: a problem for quality improvement. | PSNet
    psnet.ahrq.gov/issue/incident-reporting-system-does-not-detect-adverse-drug-events-problem-quality-improvement
    February 10, 2011 - Classic Incident reporting system does not detect adverse drug events: a problem … The incident reporting system does not detect adverse drug events: a problem for quality improvement. … The incident reporting system does not detect adverse drug events: a problem for quality improvement.

44. Quality, Safety, and Noninterpretive Skills. | PSNet
    psnet.ahrq.gov/issue/quality-safety-and-noninterpretive-skills
    November 11, 2015 - Increased radiation exposure has emerged as a patient safety problem , with the potential to result … November 11, 2015 Organizational Learning from Experience in High-Hazard Industries: Problem

45. Diagnostic Error in Medicine. | PSNet
    psnet.ahrq.gov/issue/diagnostic-error-medicine
    October 22, 2013 - of 12 articles drawn from a 2008 conference on diagnostic error , covering topics such as medical problem … Related Resources From the Same Author(s) Diagnostic Error: Is Overconfidence the Problem

46. Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician phone communication: a randomized trial. | PSNet
    psnet.ahrq.gov/issue/evaluation-problem-specific-sbar-tool-improve-after-hours-nurse-physician-phone-communication
    December 30, 2014 - Study Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician … Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician phone communication … Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician phone communication

47. How not to waste a crisis: a qualitative study of problem definition and its consequences in three hospitals. | PSNet
    psnet.ahrq.gov/issue/how-not-waste-crisis-qualitative-study-problem-definition-and-its-consequences-three
    April 21, 2015 - Study How not to waste a crisis: a qualitative study of problem definition and its … How not to waste a crisis: a qualitative study of problem definition and its consequences in three hospitals … How not to waste a crisis: a qualitative study of problem definition and its consequences in three hospitals

48. Understanding human over-reliance on technology. | PSNet
    psnet.ahrq.gov/issue/understanding-human-over-reliance-technology
    February 24, 2016 - technology can diminish human decision-making, this newsletter article offers strategies to address the problem … May 7, 2018 Reporting and second-order problem solving can turn short-term fixes into

49. Indication alerts intercept drug name confusion errors during computerized entry of medication orders. | PSNet
    psnet.ahrq.gov/issue/indication-alerts-intercept-drug-name-confusion-errors-during-computerized-entry-medication
    August 28, 2019 - medications were ordered and required users to click "OK" to ignore the alert, to add the drug to a problem … August 4, 2021 Indication alerts to improve problem list documentation.

50. Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational study of consecutive intensive care unit patients. | PSNet
    psnet.ahrq.gov/issue/insights-problem-alarm-fatigue-physiologic-monitor-devices-comprehensive-observational-study
    July 17, 2013 - Study Classic Insights into the problem of alarm fatigue … 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

51. Situational Awareness | PSNet
    psnet.ahrq.gov/taxonomy/term/3440
    April 10, 2025 - Fixation on this problem can result in loss of situational awareness to the point that steps are not

52. Retained Surgical Items: Causation and Prevention | PSNet
    psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
    January 04, 2024 - Background A retained surgical item (RSI) is a surgical patient safety problem that occurs because of … could not have been true) in 40 of the 46 (87%) retained sponge cases. 4 There must have been some problem … In these cases, counting identified a problem but communication failed. … This problem is called normalization of deviance and may drive unhealthy cultural responses (e.g., “this … Retained surgical items: overview of a persistent problem in health care.

53. Why we need a single definition of disruptive behavior. | PSNet
    psnet.ahrq.gov/issue/why-we-need-single-definition-disruptive-behavior
    November 01, 2017 - is needed to develop effective policy and research programs for responding to and addressing the problem … July 2, 2019 Problem list completeness in electronic health records: a multi-site study

54. In Conversation with...Steven J. Spear, DBA, MS, MS | PSNet
    psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
    August 01, 2009 - in care, in the ways we learned from Toyota: see a problem and know that the problem you see is something … In the moment they have the problem, the problem gets swarmed. … make the problem go away. … the problem, and solve the problem are very robust. … problem recurrence.

55. Reducing unacceptable missed doses: pharmacy assistant–supported medicine administration. | PSNet
    psnet.ahrq.gov/issue/reducing-unacceptable-missed-doses-pharmacy-assistant-supported-medicine-administration
    June 07, 2023 - Recent interventions, such as barcode medication administration systems, may help mitigate this problem … While these findings suggest a possible robust solution to this common problem, major limitations to

56. Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. | PSNet
    psnet.ahrq.gov/issue/pain-management-and-opioid-epidemic-balancing-societal-and-individual-benefits-and-risks
    March 29, 2006 - A recent PSNet perspective discussed opioid overdose as a patient safety problem. … May 20, 2020 The opioid crisis: can improving diagnosis help solve the problem?

57. Central Line Insertion Care Team Checklist. | PSNet
    psnet.ahrq.gov/issue/central-line-insertion-care-team-checklist
    October 02, 2024 - This checklist targets the persistent problem of central line-associated infections by providing critical

58. Complexity science: the challenge of complexity in health care. | PSNet
    psnet.ahrq.gov/issue/complexity-science-challenge-complexity-health-care
    March 13, 2013 - This framework necessitates replacing traditional methods of problem solving with ones that both foster … March 24, 2011 Quality of medication use in primary care—mapping the problem, working

59. Airway Obstruction during Anterior Cervical Spine Surgery | PSNet
    psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
    January 29, 2021 - the surgeon identified faulty positioning of the surgical retractor as the most likely cause of the problem … ventilator. 8 If ventilation remains inadequate after switching to the Ambu bag, the origin of the problem … An ultrasound, chest radiograph, or flexible bronchoscopy may help to diagnose the cause of the problem … Mental stress from the “blame game” makes it more difficult to solve the problem in a timely manner. … Trying to troubleshoot the equipment problem without using a bag-valve resuscitator may lead to hypoxemia

60. An Incomplete Anesthesia History Leads to Adverse Outcomes | PSNet
    psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
    January 29, 2021 - The problem also needs to be highlighted in the problem list and discharge summary of the patient’s medical … Clearly highlight the problem in the medical record A reintubation or unexpected ICU admission due … problem has been identified, it is paramount that the patient is informed about the nature of the problem … If the patient does not recognize the significance of the event, it is unlikely that the problem will … A multiple-hospital anaesthetic problem register: establishment of a regionally organized system for