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psnet.ahrq.gov/node/42131/psn-pdf
March 20, 2013 - what-surgeons-leave-behind-costs-some-patients-dearly
https://psnet.ahrq.gov/issue/retained-surgical-items-problem-yet-be-solved
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psnet.ahrq.gov/node/41023/psn-pdf
December 21, 2011 - /issue/medicine-wandering-mind-mind-wandering-medical-practice
https://psnet.ahrq.gov/issue/medical-problem-solving-analysis-clinical-reasoning
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psnet.ahrq.gov/node/42429/psn-pdf
July 17, 2013 - necessity-good-surgical-history-detection-gossypiboma
https://psnet.ahrq.gov/issue/retained-surgical-items-problem-yet-be-solved
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psnet.ahrq.gov/node/33865/psn-pdf
September 01, 2018 - At the time, British Rail had a problem in that about one in a thousand shunters
were dying every year … RL: One problem in health care is we tend to want to learn from each individual event and try to prevent … Do your
results mean that hearing about a safety problem from a patient doesn't make it any more likely … The problem is that some people just don't want
to be involved. … The problem is creating potential inequalities in health if we rely on that level of involvement.
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psnet.ahrq.gov/node/49558/psn-pdf
April 01, 2008 - rare but dangerous reactions such as Clostridium difficile colitis, anaphylaxis, or this
patient's problem … The chief population-level effect of antibiotic overuse is the widespread and growing problem of
antimicrobial … AMR is a worsening problem among many bacteria, including
Staphylococcus aureus, Streptococcus pneumoniae … While the
complications and ultimate outcome of this case are exceedingly rare, unfortunately, the problem … Staphylococcus aureus (MRSA) (18) is but one example of the clinical implications of
drug-resistant bacteria—a problem
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psnet.ahrq.gov/node/33834/psn-pdf
May 22, 2017 - Opioid Overdose as a Patient Safety Problem
May 22, 2017
Murimi IB, Alexander CG. … Opioid Overdose as a Patient Safety Problem. PSNet [internet]. 2017. … https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
Perspective
Opioids serve … https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
https://psnet.ahrq.gov//#ref1
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psnet.ahrq.gov/node/42866/psn-pdf
January 22, 2014 - lawyers often choose not to accept
medical error cases and found financial factors contribute to the problem
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psnet.ahrq.gov/node/35460/psn-pdf
June 17, 2014 - drug names, mistakes that can result from them, and
successful hospital initiatives to combat the problem
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psnet.ahrq.gov/node/37602/psn-pdf
July 03, 2013 - The authors discuss the implications of this problem and potential
solutions, including the establishment
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psnet.ahrq.gov/node/44429/psn-pdf
May 10, 2016 - clinical-reasoning-toolkit
https://psnet.ahrq.gov/issue/clinical-reasoning-toolkit
https://psnet.ahrq.gov/issue/medical-problem-solving-analysis-clinical-reasoning
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psnet.ahrq.gov/node/35576/psn-pdf
December 23, 2012 - pediatric research and clinical practice improvement,
organizing information into four key categories: problem
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psnet.ahrq.gov/node/33957/psn-pdf
February 05, 2018 - have enacted legislation to support the development of state patient safety centers to address
the problem
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psnet.ahrq.gov/node/35917/psn-pdf
July 23, 2010 - whether nursing staff could hear patient care alarms over background noises
and found audibility to be a problem
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psnet.ahrq.gov/node/46918/psn-pdf
May 30, 2018 - workplace-bullying-risk-and-safety-professionals
Disruptive and unprofessional behavior is a prevalent problem
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psnet.ahrq.gov/node/39941/psn-pdf
October 20, 2010 - normalization-deviance-do-we-unknowingly-accept-doing-wrong-thing
This commentary describes normalization of deviance and uses examples to illustrate how this problem
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psnet.ahrq.gov/node/33752/psn-pdf
August 01, 2013 - They oftentimes
will say, "Well, the problem around here is that Mark's an idiot. … we work with a lot of different health care systems and many of them
think that they know what the problem … interviews or spend a little time doing a debriefing with staff you'll find out that they've got a problem … If you tailor the tools to address the problem based on
a cultural assessment that's reflective of the … And do you really know what to do about that if that's the
problem?
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psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd
November 01, 2006 - They analyze the problem, they analyze the possible solutions, and they design a solution. … Now anybody who designs anything has a problem of understanding the thing they're designing too well, … RW: Is it purely a problem of the expert having trouble recognizing what novices do and don't know? … So part of the problem is not seeing it as a system, that things have to work in context. … The problem is we tend to deny it.
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psnet.ahrq.gov/perspective/conversation-barbara-drew-rn-phd
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.
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psnet.ahrq.gov/node/33691/psn-pdf
December 01, 2009 - How to Identify and Manage Problem Behaviors
December 1, 2009
Rosenstein AH, O'Daniel M. … How to Identify and Manage Problem Behaviors. PSNet [internet]. 2009. … https://psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors
Perspective
The 1999 Institute … compromises in quality and mortality).(7)
https://psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors … Once we defined the extent of the problem and the relationship between disruptive behaviors and both
-
psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
November 01, 2006 - They analyze the problem, they analyze the possible solutions, and they design a solution. … Now anybody who designs anything has a problem of understanding the thing they're designing too well, … RW: Is it purely a problem of the expert having trouble recognizing what novices do and don't know? … So part of the problem is not seeing it as a system, that things have to work in context. … The problem is we tend to deny it.