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Showing results for "problem".

421. Natural history of retained surgical items supports the need for team training, early recognition, and prompt retrieval. | PSNet
     psnet.ahrq.gov/issue/natural-history-retained-surgical-items-supports-need-team-training-early-recognition-and
     January 18, 2013 - Citation Related Resources From the Same Author(s) Retained surgical items: a problem … November 25, 2015 Retained surgical items: a problem yet to be solved.

422. Disclosure of medical error: policies and practice. | PSNet
     psnet.ahrq.gov/issue/disclosure-medical-error-policies-and-practice
     June 30, 2011 - August 25, 2021 Human error and the problem of causality in analysis of accidents. … March 4, 2020 How not to waste a crisis: a qualitative study of problem definition and

423. Development of a conceptual map of negative consequences for patients of overuse of medical tests and treatments. | PSNet
     psnet.ahrq.gov/issue/development-conceptual-map-negative-consequences-patients-overuse-medical-tests-and
     November 01, 2017 - April 17, 2019 Overdiagnosis in primary care: framing the problem and finding solutions … September 12, 2018 Overdiagnosis and overtreatment as a quality problem: insights from

424. Scoring no goal—further adventures in transparency. | PSNet
     psnet.ahrq.gov/issue/scoring-no-goal-further-adventures-transparency
     August 02, 2015 - Fall; Part 2: Cursed By Knowledge: Building a Culture of Psychological Safety; and Part 3: The Not-My-Problem … Problem.

425. ReCASTing the RCA: an improved model for performing root cause analyses. | PSNet
     psnet.ahrq.gov/issue/recasting-rca-improved-model-performing-root-cause-analyses
     November 10, 2010 - January 29, 2020 Root Cause Analysis: The Core of Problem Solving and Corrective Action … September 27, 2017 The problem with root cause analysis.

426. Managing the patient identification crisis in healthcare and laboratory medicine. | PSNet
     psnet.ahrq.gov/issue/managing-patient-identification-crisis-healthcare-and-laboratory-medicine
     April 22, 2009 - January 7, 2011 Addressing racial and ethnic bias in pulse oximeters—a wicked problem … June 16, 2019 The wicked problem of patient misidentification: how could the technological

427. Residents' duty hours—toward an empirical narrative. | PSNet
     psnet.ahrq.gov/issue/residents-duty-hours-toward-empirical-narrative
     March 28, 2018 - Fall; Part 2: Cursed By Knowledge: Building a Culture of Psychological Safety; and Part 3: The Not-My-Problem … Problem.

428. Investigating the causes of adverse events. | PSNet
     psnet.ahrq.gov/issue/investigating-causes-adverse-events
     October 03, 2017 - October 7, 2013 Retained surgical items: a problem yet to be solved. … September 24, 2016 The problem with the '5 whys.'

429. Root cause analysis of reported patient falls in ORs in the Veterans Health Administration. | PSNet
     psnet.ahrq.gov/issue/root-cause-analysis-reported-patient-falls-ors-veterans-health-administration
     January 17, 2019 - Retained guidewires in the Veterans Health Administration: getting to the root of the problem … Related Resources Patient falls in the operating room: why is this still a problem

430. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33833/psn-pdf
     May 01, 2017 - So it's very gratifying to have a common problem—pain—and a tool to treat it in the form of strong opioids … One other problem that has a bearing on what we know about the long-term safety and effectiveness of … The problem is that we cannot identify a priori which patients are going to be benefitted more than … RW: Do you think the health care system is set up to manage this problem? … lends itself to a quick encounter, and there's a societal expectation that there's a pill for every problem

431. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49540/psn-pdf
     August 21, 2007 - Resuscitation Errors: A Shocking Problem August 21, 2007 Edelson DP, Abella BS. … Resuscitation Errors: A Shocking Problem. PSNet [internet]. 2007. … https://psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem Case Objectives Appreciate that … more than 300,000 lives each year in the United States alone.(1) SCA presents a difficult clinical problem … ameliorates this effect, this protection https://psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem

432. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49460/psn-pdf
     September 01, 2004 - She did, but relayed that her mentor was unconcerned with this problem. … office contacted the student for further description of the violation, and within a week the security problem … The total time elapsed between the student's initial identification of the problem and the hospital's … represents a common situation in which a medical student, having noticed an error, is confronted with the problem

433. Good Catch in the Operating Room | PSNet
     psnet.ahrq.gov/web-mm/good-catch-operating-room
     August 27, 2017 - An acronym for key expressions containing code words signaling a potential urgent safety problem, the … " or "This is a S afety issue," it indicates that the member wants to "stop the line" to address a problem … Third, she stated what she felt was the perceived problem of unrecognized hemorrhage. … Fourth, she offered her solution by suggesting to stop the procedure and figure out the problem. … Take-Home Points The CUS Tool can help alert other team members to a safety problem and should prompt

434. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49466/psn-pdf
     October 14, 2004 - charts to draw the attention of treating physicians to a particularly important recent lab result or problem … The problem, as illustrated in this case, is that sometimes information in the medical record is not … Chart flags, color-coded consult notes, follow-up checklists, and multidisciplinary problem lists have … The hospital where this case occurred has suggested an organizational solution to the problem. … In this case, an NPO order was the problem, but the root cause analysis revealed general problems with

435. Transitional chaos or enduring harm? The EHR and the disruption of medicine. | PSNet
     psnet.ahrq.gov/issue/transitional-chaos-or-enduring-harm-ehr-and-disruption-medicine
     August 02, 2015 - Fall; Part 2: Cursed By Knowledge: Building a Culture of Psychological Safety; and Part 3: The Not-My-Problem … Problem.

436. Errors in after-hours phone consultations: a simulation study. | PSNet
     psnet.ahrq.gov/issue/errors-after-hours-phone-consultations-simulation-study
     March 21, 2017 - Download Citation Related Resources From the Same Author(s) Evaluation of a problem-specific … February 10, 2021 Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician

437. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49719/psn-pdf
     September 01, 2014 - After discovering the error, the case continued without any problem. … Documenting a value when it wasn't measured is the opposite of the commonly occurring problem where … a user intimately familiar with this patient's monitor would have identified, and rectified, this problem … approach to preventing this error would be to use the electronic anesthesia record to identify the problem … support may have led to better situational awareness and helped clinicians identify this patient's problem

438. Reducing the Safety Hazards of Monitor Alert and Alarm Fatigue | PSNet
     psnet.ahrq.gov/perspective/reducing-safety-hazards-monitor-alert-and-alarm-fatigue
     May 01, 2016 - monitor alarms are false or clinically insignificant.( 2-5 ) Hospitals are struggling to address this problem … RW : When you first began investigating this, did you have a theory as to what the problem was, and did … 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. … September 1, 2016 Insights into the problem of alarm fatigue with physiologic monitor

439. Harm From Alarm Fatigue | PSNet
     psnet.ahrq.gov/web-mm/harm-alarm-fatigue
     February 14, 2018 - This patient's telemetry device warned of this problem with "low voltage" alarms. … alarms that indicate poor signal quality (e.g., a low battery in a telemetry device, an electrode problem … Take-Home Points Alarms should never be completely silenced; rather, clinical staff should problem-solve … Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational … October 10, 2012 Insights into the problem of alarm fatigue with physiologic monitor

440. In Conversation with…William B. Weeks, MD, MBA | PSNet
     psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
     May 01, 2009 - the economic consequences of errors and saw that they really did cost someone money, how much of the problem … WW : That is exactly the problem in a nutshell. … Another problem might be that they're not owned medical staff, if you will. … RW: Is part of the problem that the people who come into health care from a business background don't … We also do a better job communicating vital safety information (medication and problem lists, allergies