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www.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-mental-health-bmjqs.pdf
April 15, 2024 - We found that diagnostic
error is well understood to be a problem in mental
healthcare. … For instance, while the
NASEM model includes the initial steps of experi-
encing a health problem and … Diagnostic issues and controversies in DSM-5:
return of the false positives problem. … Overdiagnosis in primary
care: framing the problem and finding solutions. … NCHS Data Brief the problem and moving toward solutions.
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0085episiotomycoding.xls
January 01, 2012 - Performance Improvement(R) (AMA-PCPI) 2.16.840.1.113883.3.526.3.1389 Shoulder Dystocia Condition/Diagnosis/Problem … Performance Improvement(R) (AMA-PCPI) 2.16.840.1.113883.3.526.3.1389 Shoulder Dystocia Condition/Diagnosis/Problem … Performance Improvement(R) (AMA-PCPI) 2.16.840.1.113883.3.526.3.1389 Shoulder Dystocia Condition/Diagnosis/Problem … Performance Improvement(R) (AMA-PCPI) 2.16.840.1.113883.3.526.2.1488 Shoulder Dystocia Condition/Diagnosis/Problem … Performance Improvement(R) (AMA-PCPI) 2.16.840.1.113883.3.526.2.1488 Shoulder Dystocia Condition/Diagnosis/Problem
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www.ahrq.gov/ncepcr/about/index.html
December 01, 2024 - produced a summary report and primary care research agenda centered on the patient, the practitioner, the problem
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www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-patient-experience-vol2.pdf
July 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 … switched doctors after the event; a comparable percentage switched hospitals if they had a diagnostic
problem … ■ Open-ended questions should be designed to provide information about both the emergence of the
problem
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www.ahrq.gov/hai/tools/surgery/about.html
December 01, 2017 - To address this problem, the Agency for Healthcare Research and Quality (AHRQ) funded a 3-year project
-
www.ahrq.gov/patient-safety/settings/esrd/resource/tooldev.html
January 01, 2015 - To address this problem, the Agency for Healthcare Research and Quality (AHRQ) funded the National Opportunity
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care-2/tools.html
July 01, 2023 - Involves describing the patient situation (S), patient background (B), problem assessment (A), and recommended
-
www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/psychological-safety-slides.pdf
March 18, 2025 - challenges on the unit
• Reflecting and evaluating noted 161 times
• 368 observed events of staff problem … high reliability
Is there a Daily Management System
Psychological safety
Escalation, triage, and problem
-
www.ahrq.gov/patient-safety/reports/liability/silence.html
August 01, 2017 - families want after medical harm has occurred: tell us what happened, tell us how you are going to fix the problem … Some people need to do this to make sure the problem or system is fixed, others do it to honor their
-
www.ahrq.gov/news/events/nac/2019-07-nac/nacmtg0719-minutes.html
November 01, 2019 - Bierman asked the NAC members to consider four questions:
What is the scope of this problem? … What terms describe this problem?
How is the issue being talked about in your organization? … He recognized a major problem—decisionmakers often lack access to timely, reliable data and analytics … AHRQ has a 5-year agenda to attack the problem. … To solve that problem, AHRQ is seeking to support and promote patient safety strategies, predictive analytics
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_3_communication.pptx
July 01, 2023 - call-out is occurring, explaining the situation, what the risks are, and what is being done about the problem … Assessment―What do I think the problem is?
Recommendation―What would I recommend?
Tip! … Assessment—What do I think the problem is?
Recommendation—What would I recommend? … Recognition
Every Patient Response
Every Case Reporting
Every Unit
N/A During Handoffs:
Review patient problem … During recognition of obstetric hemorrhage, you should review the patient problem list and communicate
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_3-communication-speaker-notes.pdf
July 01, 2023 - o Assessment―What do I think the problem is?
o Recommenda�on―What would I recommend?
Tip! … • Assessment—What do I think the problem is?
• Recommendation—What would I recommend? … events; while
providing updates to other team members or the patient and family members; and when
problem … like SBAR or I PASS THE BATON
• Verbally communicate as much as possible
• Discuss the patient problem … During recognition of
obstetric hemorrhage, you should review the patient problem list and communicate
-
www.ahrq.gov/talkingquality/explain/share-info/highlight.html
September 01, 2019 - clear guidance to consumers on making a formal complaint if they or their loved ones have experienced a problem
-
www.ahrq.gov/talkingquality/plan/quality-measures.html
November 01, 2018 - Containment Council has published several public reports that each focus on a particular kind of health problem
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/diagnostic-toolkit/02-pfe-road-map.pdf
August 01, 2021 - about incidents of diagnostic
errors that are useful to engage leadership and raise awareness of the
problem
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/diagnostic-safety-pilot-study-report.pdf
April 01, 2021 - item “The amount of time for appointments is long enough to fully
evaluate the patient’s presenting problem … “The amount of time
for appointments is
long enough to fully
evaluate the patient’s
presenting
problem … office have enough
time to review the
relevant information
related to the
patient’s presenting
problem
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www.ahrq.gov/teamstepps-program/curriculum/mutual/overview/index.html
July 01, 2023 - State the problem (real or perceived).
Offer a solution.
Reach agreement on next steps.
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/2022-hsops2-database-report-appendixes.pdf
January 01, 2022 - (Item A8) 86% 87% 87% 87% 85%
% Strongly Disagree/Disagree
There is a problem with disrespectful … (Item A8) 86% 85% 86% 88% 89% 85% 87% 88% 87%
% Strongly Disagree/Disagree
There is a problem with … (Item A8) 87% 79% 83% 88% 88% 94% 84% 84% 89% 87%
% Strongly Disagree/Disagree
There is a problem … (Item A8) 92% 85% 82% 84% 87% 88% 87% 82% 87%
% Strongly Disagree/Disagree
There is a problem with … (Item A8) 87% 88%
% Strongly Disagree/Disagree
There is a problem with disrespectful behavior by
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/2021-HSOPS2-Database-Report-Part-II-508.pdf
January 01, 2021 - (Item A8) 86% 88% 87% 87%
% Disagree/Strongly Disagree
There is a problem with disrespectful behavior … (Item A8) 86% 86% 88% 89% 87% 87%
% Disagree/Strongly Disagree
There is a problem with disrespectful … (Item A8) 89% 78% 85% 93% 89% 94% 84% 83% 90% 87%
% Disagree/Strongly Disagree
There is a problem … (Item A8) 92% 86% 83% 86% 89% 88% 87% 83% 88%
% Disagree/Strongly Disagree
There is a problem with … (Item A8) 87% 89%
% Disagree/Strongly Disagree
There is a problem with disrespectful behavior by
-
www.ahrq.gov/cahps/surveys-guidance/item-sets/cg/suppl-pcmh-items-cg-survey30-child.html
August 01, 2021 - In the last 6 months, did your child see a specialist for a particular health problem?