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www.ahrq.gov/sites/default/files/2025-03/greenes-report.pdf
January 01, 2025 - SCOPE
The problem of late-arriving laboratory data:
Failure to act on results of monitoring or testing … Application of medical errors theory to the problem of late-arriving laboratory data:
Medical errors … The problem of late-arriving laboratory data in the ED is well understood using
this model. … To address the problem of late-arriving laboratory data in the ED, we developed a
computerized system … The problem of medical errors attributable to inadequate follow-up of late-
arriving laboratory data
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/communication-slides.pptx
November 01, 2019 - and Teamwork
AHRQ Safety Program for Improving Antibiotic Use – Acute Care
3
The single biggest problem … Be hard on the problem, not the people. … Advocacy and Assertion
An assertive statement should:3
Open the discussion
State the concern
State the problem
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www.ahrq.gov/sites/default/files/publications/files/ltcmodule1.pdf
June 01, 2012 - We’ve all been in difficult situations that might have been avoided
if we had noticed a problem early … These kinds of changes
put the resident at risk for falling and also may signal an underlying problem … , and to
detect a problem requiring new treatment. … If you only reported things that turned
out to be a problem, you would probably have missed some. … Sometimes the nursing assistant needs to report the
problem again to the licensed nurse.
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www.ahrq.gov/hai/cauti-tools/ena-slides/part1.html
October 01, 2020 - These decisions involve problem identification, acuity assignment, acquisition of resources, and patient … When looking at this from a CAUTI perspective, some relevant questions are:
Problem identification … Slide 26
The role of the emergency nurse
Problem identification. … Questions around ownership: Whose problem is it?
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/coordination/ccqmpc/ccqm-pc-survey-instructions.pdf
July 01, 2016 - 1 Never
2 Sometimes
3 Usually
4 Always
5 I did not have a health problem
in the last 12 months … In the last 12 months, if you had a
health problem, how often did your
primary care provider or other … In the last 12 months, did you get health
care 3 or more times for the same
condition or problem? … Is this a condition or problem that has
lasted for at least 3 months? … Any other emotional
problem?
Substance problems
(drugs or alcohol)?
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/urine-culturing/when-to-order/role-play.html
May 01, 2017 - A ssessment – What did Nurse Nohai think was the problem? … Bell does not usually have a problem getting around, but he fell three times in the past week. … A ssessment:
What do you think the problem is? … A ssessment:
What do you think the problem is?
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/new-sops-workplace-safety-zebrak.pdf
July 22, 2022 - Negatively worded survey item:
In this unit, there is a problem with patients or visitors being physically … Patients or Visitors
Average % Positive Response
(Strongly Disagree/Disagree)
In this unit, there is a problem … In this unit, there is a problem with patients or visitors being
verbally aggressive toward providers … Providers or Staff
Average % Positive Response
(Strongly Disagree/Disagree)
In this unit, there is a problem
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide167.html
October 01, 2014 - Type of counseling and behavioral therapies
Counseling should include practical counseling (problem-solving
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Keller.pdf
January 01, 2004 - The ventilator reports, which typically
involve a breathing circuit failure or alarm problem that can … , (i.e., the manufacturer, the distributor, the
FDA, etc.) whom to contact for assistance, how the problem … organizations,
clinical literature, ECRI product evaluations and investigations of member
hospital problem … Typical feedback included statements that the reported problem did not apply
based on a check of the … hospital inventory or on an account of the steps taken to
resolve the problem (e.g., confirmation that
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www.ahrq.gov/sites/default/files/2024-01/holland-report.pdf
January 01, 2024 - They compiled a ‘user-friendly’ risk tool of seven
variables: use of problem medications, depression … A
problem with the tool is that nearly every hospitalized patient screens in. … recovery experience and that are recognized as
important factors likely to impact readmission.19-21 A problem … consistent with results of the ESDP when
used in an academic medical center.25 Of the five subscales of problem … high ESDP scores also had, on average, higher percentages of unmet needs in four of the five subscale
problem
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/infectious-complications-transcript.doc
September 09, 2014 - The issue is with inappropriate and microbial use I think is a major problem. … Another problem with a pressure with antibiotics and their side effects and physical, more resistant … There is a problem. … It spread very rapidly and is now a global problem. 6 percent of eyes lives at UW are the Nap I or the … The problem that we’re running into with maintaining Foleys is we really don’t have any great ideas for
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www.ahrq.gov/hai/cauti-tools/archived-webinars/infectious-complications-transcript.html
November 01, 2015 - The issue is with inappropriate and microbial use I think is a major problem. … Another problem with a pressure with antibiotics and their side effects and physical, more resistant … There is a problem. … It spread very rapidly and is now a global problem. 6 percent of eyes lives at UW are the Nap I or the … The problem that we're running into with maintaining Foleys is we really don't have any great ideas for
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-3.html
June 01, 2023 - framing as “diagnostic errors,” since an error is seen by patients as implying culpability for the problem … Considering only respondents for whom the diagnostic problem happened 3 or more years in the past, 28 … events will also be the most undercounted by surveys fielded by the delivery systems within which the problem … Open-ended questions should be designed to provide information about both the emergence of the problem … switched doctors after the event; a comparable percentage switched hospitals if they had a diagnostic problem
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Thomadsen.pdf
December 23, 2004 - Far too often the
responses consist of new rules that prevent that particular problem from arising … The facility had a problem with preventive maintenance of its
Advances in Patient Safety: Vol. 2 … Safety culture
probably remains a problem without resolution, in which case the investigation
should … The absence of an available method (i.e., no protocol or an ineffective
protocol) for detecting the problem … The
problem with following that recommendation, of course, is that the more active
and effective tools
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Zhang.pdf
January 01, 2004 - We will describe the usability
heuristics, the scale for severity rating of usability problem, and the … at all.
1 = Cosmetic problem only. … Need not be fixed unless extra time is
available.
2 = Minor usability problem. … Fixing should be given low priority.
3 = Major usability problem. … A single usability problem
identified by an evaluator can be violations of multiple heuristics, which
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide30.html
October 01, 2014 - and clinicians should use these when counseling patients making a quit attempt: Practical counseling (problem-solving
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-overview/slide48.html
October 01, 2014 - clinicians should use these when counseling patients making a quit attempt:
Practical counseling (problem
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www.ahrq.gov/talkingquality/translate/compare/order.html
November 01, 2018 - However, this problem can be mitigated in Web-based reports; for example:
The site could permit a … Advantages to Ordering Within Cost Tiers
This approach avoids a major problem with presenting cost
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/16-engaging-stakeholders-pitch.docx
June 01, 2023 - What problem do you want to solve? … - Enter here
What problem do you want to solve?
- Enter here
Why is ISCR the solution?
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/assertion-slides/Assertion-Dec-14-2010-508.ppt
January 01, 2010 - patient
Depersonalize the conversation
Actively avoid being perceived as judgmental
Be hard on the problem … “In This ICU, It Is Difficult To Speak Up If I Perceive A Problem With Patient Care.”
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#32.