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www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-slides.html
December 01, 2017 - Use the Learning From Defects (LFD) tool to perform second-order problem solving. … Slide 4: Problem-Solving Hierarchy
Example: Missing equipment in line cart
First-order problem … Red arrow pointing down is captioned "First-order problem-solving." … Green arrow pointing up is captioned "Second-order problem-solving." … Build second-order problem solving skills necessary to learn from defects.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-facguide.docx
January 01, 2017 - Slide 5
Problem-Solving Hierarchy
SAY:
First-order problem solving resolves an issue for one patient … ASK:
What method of problem solving should we employ? … SAY:
Instead of relying on first-order problem solving, practice second-order problem solving. … Slide 6
Problem-Solving Goal
SAY:
First-order problem solving addresses the immediate need but does … ASK:
How can you make sure that everyone is aware of the problem?
-
www.ahrq.gov/evidencenow/tools/burnout-in-primary-care.html
March 01, 2023 - Resource: Burnout in Primary Care (PDF, 1.5 MB, 16 pages)
Burnout is a serious and growing problem
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/red-toolkit/ahcpsample.pdf
September 01, 2012 - Question or Problem with this Packet? … Call your Discharge Educator: (555) 555-2222
Serious health problem? Call Dr. … :
Noncardiac Chest
Pain
Noncardiac chest pain is pain that is not caused by a heart
problem. … See your doctor and ask questions.
11
My Medical Problem:
High Blood Pressure
High … AveryFor my appointment onWednesday, August 8th, at 11:30 am
My Medical Problem:
-
www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/part2-sbuse.html
May 01, 2018 - Same
No Change
People age 12 and over who needed treatment for illicit drug use or an alcohol problem … Substance Abuse Treatment
People age 12 and over who needed treatment for illicit drug use or an alcohol problem … noninstitutionalized population age 12 and over who needed treatment for illicit drug use or an alcohol problem … 2012, only 10.8% of people age 12 and over who needed treatment for illicit drug use or an alcohol problem
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/red-toolkit/postdisphone.docx
April 07, 2025 - Using your own words, can you explain to me what your main problem or diagnosis is? … CALLER: Do you have any questions for me about your main problem [diagnosis]? … CALLER: Since you left the hospital, do you feel your main problem, [diagnosis], has improved, worsened … What To Do If a Problem Arises
CALLER: Before we hang up, I want to make sure that if a medical problem … CALLER: And what about if you [give example of urgent but not emergent problem] in the evening?
-
www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/postdischarge-phone.html
March 01, 2025 - Using your own words, can you explain to me what your main problem or diagnosis is? … CALLER: Do you have any questions for me about your main problem [diagnosis]? … CALLER: Since you left the hospital, do you feel your main problem, [diagnosis], has improved, worsened … What To Do If a Problem Arises CALLER: Before we hang up, I want to make sure that if a medical problem … CALLER: And what about if you [give example of urgent but not emergent problem] in the evening?
-
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-reimagining-healthcare-teams-5.html
July 01, 2023 - member of dyadic diagnostic teams brings their unique perspective and skill set to address a diagnostic problem
-
www.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-slides.html
February 01, 2017 - Use the Learning from Defects (LFD) tool to perform second-order problem solving. … Slide 6: Problem-Solving Hierarchy
First-Order Problem Solving
Recovers for one patient, but … Slide 7: Problem-Solving Goal
First-order problem solving addresses immediate need, but does not … Second-order problem solving addresses future needs and improves overall patient safety culture. … Image: Counterbalanced arrows illustrate first-order problem solving versus second-order problem solving
-
www.ahrq.gov/patient-safety/settings/ambulatory/reduce-readmissions.html
December 01, 2023 - Potentially Preventable Readmissions
High rates of readmissions are a major patient safety problem
-
www.ahrq.gov/patients-consumers/diagnosis-treatment/diagnosis/index.html
December 01, 2017 - And it has tips to help you learn more about your specific problem and how it can be treated.
-
www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/training-tools/tool.html
June 01, 2017 - General capacity to improve on more than one outcome or process
Partnership itself
Problem … Problem solving: If key elements are lacking, has a strategy been developed to address this issue? … Problem solving: If positive incentives are inadequate or disincentives are identified, have strategies …
Can pick and choose among offered activities
Other
Problem … Problem solving: If change goals are not aligned and integrated with the strategic goals, performance
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/qualifications.html
December 01, 2017 - Have good problem-solving skills to deal with challenges that may arise (e.g., change in leadership,
-
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/leadership-5.html
June 01, 2021 - patient harm resulting from diagnostic error, many leaders have not addressed this growing patient safety problem
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/training-tools/sustainability-tool.docx
May 01, 2017 - process or outcome
General capacity to improve on more than one outcome or process
Partnership itself
Problem … Problem solving: If key elements are lacking, has a strategy been developed to address this issue? … Problem solving: If positive incentives are inadequate or disincentives are identified, have strategies … Changing role throughout the project
Can pick and choose among offered activities
Other
Problem … Problem solving: If change goals are not aligned and integrated with the strategic goals, performance
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/data-analysis-webcast-advancing-methods-4.pdf
March 03, 2021 - Plan/ Solutions:
Results: Patient Experience score for FY ended above Max%
DO
(I
m
pr
ov
e)
Problem … •More people returned the survey, but this was a follow-up
question to having a problem. … •Because their problem was not resolved in a way they felt
we heard their concern. … •We did not verify that we understood and addressed the
problem we thought they had. … Why •Why did we not verify that they felt our actions rectified
their problem?
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/red-toolkit/postdiscalldoc.docx
April 07, 2025 - If new problem since discharge:
Had the patient:
Contacted or seen clinician? … e.g., has not obtained, is not taking correctly, has concerns, including side effects):
Medicine 1:
Problem … patient/caregiver back
Called outpatient pharmacy and called patient/caregiver back
Other:
Medicine 2:
Problem … patient/caregiver back
Called outpatient pharmacy and called patient/caregiver back
Other:
Medicine 3:
Problem … Problems
Did patient/caregiver know what constituted an emergency and what to do if a nonemergent problem
-
www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
December 01, 2017 - Slide 4: Problem-Solving Hierarchy
Say:
First-order problem solving resolves an issue for one patient … Instead of relying on first-order problem solving, practice second-order problem solving. … Slide 5: Problem-Solving Goal
Say:
First-order problem solving doesn’t encourage a positive patient … solving to second-order problem solving. … Does the hospital reward first-order problem-solving instead of second-order problem-solving?
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/red-toolkit/ahcpsample.docx
September 01, 2012 - Question or Problem with this Packet? … Call your Discharge Educator: (555) 555-2222
Serious health problem? Call Dr. … mg gum
Gum
Chew
** Bring this Plan to ALL Appointments**
Oscar Sanchez
What is my main medical problem … :
Noncardiac Chest Pain
Noncardiac chest pain is pain that is not caused by a heart problem … My Medical Problem:
High Blood Pressure
High blood pressure is also called hypertension.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-slides.pptx
January 01, 2017 - Objectives
After this session, you will be able to—
Describe difference between first-order and second-order problem … defects in care more likely to occur
Use the Learning from Defects (LFD) tool to perform second-order problem … Hierarchy
First-Order
Problem Solving
Second-Order
Problem Solving
Recovers for one patient, but does … Learn From Defects ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
7
First-order problem … solving addresses immediate need, but does not improve patient safety culture
Second-order problem