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Total Results: 1,785 records

Showing results for "problem".

61. Interventions to reduce burnout and improve resilience: impact on a health system's outcomes. | PSNet
    psnet.ahrq.gov/issue/interventions-reduce-burnout-and-improve-resilience-impact-health-systems-outcomes
    January 10, 2018 - Burnout among health care professionals is widely understood as an organizational problem in health … September 24, 2014 Retained surgical items: a problem yet to be solved.

62. Error | PSNet
    psnet.ahrq.gov/taxonomy/term/3475
    April 05, 2025 - of omission are more difficult to recognize than errors of commission but likely represent a larger problem

63. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/41796/psn-pdf
    January 18, 2013 - Retained surgical items: a problem yet to be solved. … Retained surgical items: a problem yet to be solved. … https://psnet.ahrq.gov/issue/retained-surgical-items-problem-yet-be-solved Stories of retained surgical … https://psnet.ahrq.gov/issue/retained-surgical-items-problem-yet-be-solved https://psnet.ahrq.gov/issue

64. Beyond FMEA: the structured what-if technique (SWIFT). | PSNet
    psnet.ahrq.gov/issue/swift-new-tool-identifying-prospective-hazards
    February 03, 2021 - July 19, 2023 The problem with the '5 whys.' … September 14, 2016 The problem with Plan-Do-Study-Act cycles. … January 14, 2011 Drug-induced hypoglycaemia--new insight into an old problem.

65. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. | PSNet
    psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient
    February 21, 2020 - The problem of EHR “mis-routing” has been previously identified as a root cause of medical errors and … , in one review of IT-related malpractice claims, was identified as a contributing problem in about 10% … Harnessing the power of problem representation can help us continue to think critically about our patients … Careful constructions of problem presentations, particularly in children with chronic medical conditions … The importance of early problem representation during case presentations.

66. Effective followership: a standardized algorithm to resolve clinical conflicts and improve teamwork. | PSNet
    psnet.ahrq.gov/issue/effective-followership-standardized-algorithm-resolve-clinical-conflicts-and-improve-teamwork
    March 13, 2013 - Retained guidewires in the Veterans Health Administration: getting to the root of the problem … Related Resources Speaking up and taking action: psychological safety and joint problem-solving … Fall; Part 2: Cursed By Knowledge: Building a Culture of Psychological Safety; and Part 3: The Not-My-Problem … Problem.

67. Root Cause Analysis Gone Wrong | PSNet
    psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
    August 28, 2024 - As this case illustrates, no true learning may occur and the problem investigated may be just as likely … The problem with root cause analysis. BMJ Qual Saf. 2017;26:417-422. [go to PubMed] 5. … Risk management in a dynamic society: a modelling problem. Saf Sci. 1997;27:183-213. … Patient safety and the problem of many hands. BMJ Qual Saf. 2016;25:485-488. [go to PubMed] 24. … August 20, 2018 The problem with root cause analysis.

68. Surgical fire in the United States: 2000-2020. | PSNet
    psnet.ahrq.gov/issue/surgical-fire-united-states-2000-2020
    March 03, 2021 - September 22, 2021 Indication alerts to improve problem list documentation. … June 9, 2021 Crisis recovery in surgery: error management and problem solving in safety-critical … Related Resources Patient falls in the operating room: why is this still a problem

69. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/866395/psn-pdf
    July 23, 2024 - hospital staff to attend one-hour case review sessions, which focus on breakdowns in communication, problem … These two aspects of the innovation allow for multilevel problem-solving. … strengths of RIC go beyond a more traditional M&M model and include improvements to communication and problem-solving … This can be done by thoroughly describing the severity of the problem at the organization, and by leveraging … It may be helpful to frame the problem as a continuous quality improvement opportunity that builds on

70. Medication Safety Certificate Program. | PSNet
    psnet.ahrq.gov/issue/medication-safety-certificate-program
    September 30, 2020 - Leadership commitment to reduce medication errors can help address this safety problem.

71. Antifatness in the surgical setting. | PSNet
    psnet.ahrq.gov/issue/antifatness-surgical-setting
    October 12, 2022 - about surgeon biases toward patients who are overweight and calls for clinicians to recognize the problem

72. Eliminating Unintentionally Retained Surgical Items - Special Report. | PSNet
    psnet.ahrq.gov/issue/eliminating-unintentionally-retained-surgical-items-special-report
    December 07, 2022 - This three-part series discusses the RSI problem , RSI prevention efforts , and the role of human factors

73. Developing resilience to combat nurse burnout. | PSNet
    psnet.ahrq.gov/issue/developing-resilience-combat-nurse-burnout
    May 01, 2019 - This newsletter article discusses nurse burnout and how to reduce conditions that contribute to the problem

74. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33586/psn-pdf
    December 15, 2024 - The problem is that clinicians then ignore both the bothersome, clinically meaningless alarms and the … https://psnet.ahrq.gov/primer/computerized-provider-order-entry https://psnet.ahrq.gov/issue/insights-problem-alarm-fatigue-physiologic-monitor-devices-comprehensive-observational-study … require use of the principles of human factors engineering as well as those of informatics, as the problem … In solving the problem of alert fatigue, health care will need to look to examples from other industries

75. Hacking teamwork in health care: addressing adverse effects of ad hoc team composition in critical care medicine. | PSNet
    psnet.ahrq.gov/issue/hacking-teamwork-health-care-addressing-adverse-effects-ad-hoc-team-composition-critical-care
    October 11, 2023 - This paper describes a “hackathon” – an intensive problem-solving event commonly used in computer science

76. How administrative burdens can harm health. | PSNet
    psnet.ahrq.gov/issue/how-administrative-burdens-can-harm-health
    February 10, 2021 - administrative burdens  can separate patients from the care they need and calls for increased attention to the problem

77. Missed or Rationed Nursing Care. | PSNet
    psnet.ahrq.gov/issue/missed-or-rationed-nursing-care
    February 12, 2020 - This special issue documents the global problem of missed or rationed nursing care in a variety of

78. Diagnosing overdiagnosis: conceptual challenges and suggested solutions. | PSNet
    psnet.ahrq.gov/issue/diagnosing-overdiagnosis-conceptual-challenges-and-suggested-solutions
    September 20, 2023 - recent AHRQ WebM&M interview and perspective discussed overuse of medical care as a patient safety problem

79. In Conversation With… Charles Vincent, MPhil, PhD | PSNet
    psnet.ahrq.gov/perspective/conversation-charles-vincent-mphil-phd
    July 10, 2024 - I think that's a major problem for us. … The second thing is, the biggest problem is that the reporting system is endlessly and still tediously … And that is still a major problem. … , which is the inclination of a single system to be top down and to articulate and operationalize a problem … I'm by no means against that, but I think the problem is that it becomes so massively complicated; it's

80. Complaints as Safety Surveillance | PSNet
    psnet.ahrq.gov/web-mm/complaints-safety-surveillance
    May 05, 2021 - 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, … 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.