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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.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/overview/overview.pptx
May 01, 2017 - Healthcare Improvement (IHI) team studied 10 leading health care organizations that are addressing this problem … for frontline managers and staff
Key elements
Daily huddles
Use of visual boards at the front line
Problem-solving … jpeg
image3.jpeg
image5.tif
Daily Safety Huddle
• Standard agenda
• Data review
• Problem … tracking
Visual Management
• Outcomes over time
• Checklist compliance
• Problem log
Escalation
• … surgical checklist
• Infection control
procedures
Observation of
Safety Work:unit
lead & senior leader
Problem
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/visual/visual-mgmt.pptx
May 01, 2017 - Keep the board free of clutter
Integrate the board with daily huddles
Start simple
Manage the problem … #1: Privacy and safety measures Problem #2: We already have a visual board, focused on patient flow … Problem #3: The board is not updated consistently
Solution #1: Cover the board when not in use
Solution … jpeg
image1.jpeg
image5.tif
Daily Safety Huddle
• Standard agenda
• Data review
• Problem … tracking
Visual Management
• Outcomes over time
• Checklist compliance
• Problem log
Escalation
•
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/echo/about/209_echo-reporting-measures.pdf
January 01, 2004 - MCO
only)
Getting clinician happy with
Delays in treatment while wait for plan
approval
Problem … materials or on the Internet
Helpfulness of customer service
Filling out paperwork
Big problem … Small problem
Not a problem
Perceived
improvement
Q31
Q32
Compare ability to deal with
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psnet.ahrq.gov/node/47855/psn-pdf
June 19, 2019 - Medication Overload: America's Other Drug Problem.
June 19, 2019
Brownlee S; Garber J. … https://psnet.ahrq.gov/issue/medication-overload-americas-other-drug-problem
Overprescribing is a common … problem that contributes to patient harm. … culture of prescribing, deficits in information and knowledge, and fragmented care contribute to the
problem … https://psnet.ahrq.gov/issue/medication-overload-americas-other-drug-problem
https://psnet.ahrq.gov/issue
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/red-toolkit/postdiscalldoc.docx
June 02, 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
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/red-toolkit/ahcptemplen.pdf
June 02, 2025 - After Hospital Care Plan for: [patient name]
Discharge Date: [discharge date]
Question or Problem … Call your Discharge Educator: (xxx) xxx-xxxx DE
PHOTO HERE
Serious health problem? … 5
** Bring this Plan to ALL Appointments**
[Insert Patient Name]
What is my main medical problem
-
psnet.ahrq.gov/node/73581/psn-pdf
January 01, 2022 - Applying human factors engineering to address the
telemetry alarm problem in a large medical center. … Applying human factors engineering to address the telemetry
alarm problem in a large medical center. … https://psnet.ahrq.gov/issue/applying-human-factors-engineering-address-telemetry-alarm-problem-large … https://psnet.ahrq.gov/issue/applying-human-factors-engineering-address-telemetry-alarm-problem-large-medical-center … https://psnet.ahrq.gov/issue/applying-human-factors-engineering-address-telemetry-alarm-problem-large-medical-center
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psnet.ahrq.gov/node/47857/psn-pdf
June 14, 2019 - The wicked problem of patient misidentification: how
could the technological revolution help address … The wicked problem of patient misidentification: How could the
technological revolution help address … https://psnet.ahrq.gov/issue/wicked-problem-patient-misidentification-how-could-technological-revolution … https://psnet.ahrq.gov/issue/wicked-problem-patient-misidentification-how-could-technological-revolution-help-address … https://psnet.ahrq.gov/issue/wicked-problem-patient-misidentification-how-could-technological-revolution-help-address
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/learn_from_defects.docx
December 01, 2017 - Problem statement: If a patient is harmed in the perioperative area, a typical first response is to … First-order problem solving focuses on the here and now, work-arounds, and “quick fixes.” … Purpose of this tool: This tool helps you with second-order problem solving. … Purpose of this tool:
This tool helps you with second
-
order problem solving. … Purpose of this tool: This tool helps you with second-order problem solving.
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www.ahrq.gov/es/questions/question-builder/online.html
August 31, 2025 - Create a list of questions that you can take with you whether you are getting a checkup, talking about a problem … To talk about a health problem
To get or change a medicine
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management.html
June 01, 2017 - Word File , 261 KB; Text Version )
Example of PDSA Form ( Word File , 314 KB; Text Version )
Problem … Solving and Escalation
These resources help front line staff and leaders understand the problem-solving … and problem-escalation methods necessary to sustain improvements.
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www.ahrq.gov/nhguide/about/choosing-the-right-toolkit.html
October 01, 2016 - may be helpful to consider the following questions:
Has the nursing home identified a particular problem … If the nursing home has not identified a problem, it may want to start monitoring antimicrobial use with … This may help the antimicrobial stewardship team identify a problem on which to focus.
… expected to identify problems or opportunities for improvement, that represent high risk, high volume, or problem-prone
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www.ahrq.gov/sites/default/files/2024-10/sirio2-report.pdf
January 01, 2024 - Feedback mechanisms exist from the Problem-Solving System such that, over
time, learning should enhance … NIs have been long recognized
as a critical problem affecting the quality of healthcare and a principal … voluntarily
by these hospitals to estimate the magnitude of the healthcare-associated infections
problem … Region-Wide Problem Solving
Initiatives to Eliminate Infections: PRHI facilitated implementation of … initiatives enabled PRHI to determine the impact of region-wide reporting, information
sharing, and problem
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/overview/component-kit.docx
May 01, 2017 - .
· Well-Understood and Routinely Executed Problem-Solving and Escalation Methods. … (2) simple issues that have an obvious “just fix it” solution; (3) issues that are symptomatic of a problem … Problem Solving and Escalation
Well-understood problem solving methods (e.g., Model for Improvement; … Common understanding and execution of problem-solving methods ensures that huddles and visual management … tracking
Visual Management
• Outcomes over time
• Checklist compliance
• Problem log
Escalation
•
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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
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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?
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www.ahrq.gov/es/patient-safety/settings/hospital/red/toolkit/ahcp-template-eng.html
March 01, 2025 - Hospital Care Plan for: [patient name] [Patient name] Discharge Date: [discharge date] Question or Problem … Call your Discharge Educator: (xxx) xxx-xxxx DE PHOTO HERE Serious health problem? … for ** Bring this Plan to ALL Appointments** [Insert Patient Name] What is my main medical problem
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www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/ahcp-template-eng.html
March 01, 2025 - Hospital Care Plan for: [patient name] [Patient name] Discharge Date: [discharge date] Question or Problem … Call your Discharge Educator: (xxx) xxx-xxxx DE PHOTO HERE Serious health problem? … for ** Bring this Plan to ALL Appointments** [Insert Patient Name] What is my main medical problem
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/red-toolkit/ahcptemplen.docx
June 02, 2025 - Appointments**
After Hospital Care Plan for: [patient name]
Discharge Date: [discharge date]
Question or Problem … Call your Discharge Educator: (xxx) xxx-xxxx DE PHOTO HERE
Serious health problem? … ** Bring this Plan to ALL Appointments**
[Insert Patient Name]
What is my main medical problem