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Showing results for "problem".

221. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/850930/psn-pdf
     June 21, 2023 - Patient safety in emergency departments: a problem for health care systems? … Patient safety in emergency departments: a problem for health care systems? … https://psnet.ahrq.gov/issue/patient-safety-emergency-departments-problem-health-care-systems- international-survey … https://psnet.ahrq.gov/issue/patient-safety-emergency-departments-problem-health-care-systems-international-survey … https://psnet.ahrq.gov/issue/patient-safety-emergency-departments-problem-health-care-systems-international-survey

222. Public Inquiry Form | Agency for Healthcare Research and Quality
     www.ahrq.gov/contact/support.html
     September 15, 2025 - Submit a Message to Our Support Team Ask us a question, report a problem, or send feedback about Agency … Back to FAQs   Type (Required): -- Select One -- Ask a Question Provide Feedback Report a Problem

223. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50707/psn-pdf
     December 04, 2019 - Spinal surgery complications: an unsolved problem-Is the World Health Organization Safety Surgical Checklist … Spinal surgery complications: an unsolved problem-Is the World Health Organization Safety Surgical Checklist … https://psnet.ahrq.gov/issue/spinal-surgery-complications-unsolved-problem-world-health-organization- … https://psnet.ahrq.gov/issue/spinal-surgery-complications-unsolved-problem-world-health-organization-safety-surgical … https://psnet.ahrq.gov/issue/spinal-surgery-complications-unsolved-problem-world-health-organization-safety-surgical

224. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47629/psn-pdf
     July 11, 2019 - How not to waste a crisis: a qualitative study of problem definition and its consequences in three hospitals … How not to waste a crisis: a qualitative study of problem definition and its consequences in three hospitals … https://psnet.ahrq.gov/issue/how-not-waste-crisis-qualitative-study-problem-definition-and-its- consequences-three … https://psnet.ahrq.gov/issue/how-not-waste-crisis-qualitative-study-problem-definition-and-its-consequences-three … https://psnet.ahrq.gov/issue/how-not-waste-crisis-qualitative-study-problem-definition-and-its-consequences-three

225. Improving Communication and Teamwork in the Surgical Environment
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/implementation-guide/appendix-k-blank-template.pptx
     June 02, 2025 - Program for Ambulatory Surgery Implementation Guide Appendix K – Quality Improvement Study Framework 1 Problem … Statement problem statement here> Quality Improvement Study Template | ‹#› AHRQ Safety … Ambulatory Surgery Implementation Guide Appendix K – Quality Improvement Study Framework 9 Cause of the Problem … problem> Quality Improvement Study Template | ‹#› AHRQ Safety

226. Job Aid: 5 Whys and Fishbone Diagrams (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-5-whys.pdf
     June 02, 2025 - Create a problem statement, such as, “Patients have stopped attending our diabetes self-management classes … Design a change or counter-measure to correct the problem. … Create a problem statement and write it at the "head" of the fish. This is the "effect." 2.

227. Postdiscalldoc (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/red-toolkit/postdiscalldoc.pdf
     June 02, 2025 - If new problem since discharge: Had the patient:  Contacted or seen clinician? … including side effects): Medicine 1: ________________________________________________________________ Problem … _________________ Medicine 2: _________________________________________________________________ Problem … _________________ Medicine 3: _________________________________________________________________ Problem … Problems Did patient/caregiver know what constituted an emergency and what to do if a nonemergent problem

228. PowerPoint Presentation: Learn From Defects Through Sensemaking
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects.pptx
     December 01, 2017 - Instead of relying on first-order problem solving, practice second-order problem solving. … ACTIVITY: What are your examples of first-order problem solving? … How can you translate this into second-order problem solving? … solving to second-order problem solving. … Does the hospital reward first-order problem-solving instead of second-order problem-solving?

229. Strategies for Improving Patient Experience with Ambulatory Care: Service Recovery Programs (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/access/cahps-strategy-6-p.pdf
     November 02, 2017 - The Problem No matter how well you manage the customer service at your organization, problems are inevitable … Fix the problem quickly and fairly. 4. Offer atonement. 5. Follow up. 6. … Involve the person in helping to solve the problem. … They include a process for tracking problems and complaints to help identify the source of the problem … The Problem 6.P.2. The Intervention 6.P.3. Implementing This Intervention 6.P.4.

230. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836927/psn-pdf
     April 13, 2022 - The problem with making Safety-II work in healthcare. … The problem with making Safety-II work in healthcare. … https://psnet.ahrq.gov/issue/problem-making-safety-ii-work-healthcare The Safety-II framework uses a … https://psnet.ahrq.gov/issue/problem-making-safety-ii-work-healthcare https://psnet.ahrq.gov/issue/safety-i-safety-ii-white-paper

231. Management Practices for Sustainability - Module 2: Daily Huddles | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/huddles-slides.html
     June 01, 2017 - work by staff, the daily safety huddle, visual management, escalation, observation of safety work, problem … than one department Slide 10: Testing and Implementation: Common Problems and Tips Problem … #1: Huddles don’t take place when facilitator is absent or busy Problem #2: Staff turnover has … made sustaining the huddle difficult Problem #3: Staff seem not to see the benefit of the huddle

232. Shared Learning and the Drive to Improve Patient Safety: Lessons Learned from the Pittsburgh Regional Healthcare Initiative (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Sirio.pdf
     June 15, 2003 - However, the issues that arise are (1) approaching patient safety as a systems problem, and (2) overcoming … Problem-solving transforms knowledge into learning through the creation of new standards, processes, … Implementing regionwide problem-solving PRHI has supported regionwide problem-solving through the development … • Implementing rapid root-cause problem-solving at all levels of an organization. … Infection control—a problem for patient safety. N Engl J Med 2003 Feb 13;348(7):651–6.

233. Architecture | Digital Healthcare Research
     digital.ahrq.gov/technology/architecture
     January 01, 2023 - Hettinger, Aaron Zachary Project Name Cognitive Engineering for Complex Decisionmaking & Problem … Solving in Acute Care Cognitive Engineering for Complex Decisionmaking & Problem … Cognitive Engineering for Complex Decisionmaking & Problem Solving in Acute Care - Final Report. … Hettinger, Aaron Zachary Project Name Cognitive Engineering for Complex Decisionmaking & Problem … Value in a Community Network Cognitive Engineering for Complex Decisionmaking & Problem

234. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836717/psn-pdf
     March 09, 2022 - The problem with…using stories as a source of evidence and learning. March 9, 2022 Iedema R. … The problem with … using stories as a source of evidence and learning. … https://psnet.ahrq.gov/issue/problem-withusing-stories-source-evidence-and-learning Patients and families … https://psnet.ahrq.gov/issue/problem-withusing-stories-source-evidence-and-learning https://psnet.ahrq.gov

235. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46804/psn-pdf
     January 01, 2021 - Retained guidewires in the Veterans Health Administration: getting to the root of the problem. … Retained Guidewires in the Veterans Health Administration: Getting to the Root of the Problem. … https://psnet.ahrq.gov/issue/retained-guidewires-veterans-health-administration-getting-root-problem … https://psnet.ahrq.gov/issue/retained-guidewires-veterans-health-administration-getting-root-problem

236. Antibiotic-Targets-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-targets-facilitator-guide.docx
     June 01, 2021 - First-order problem solving involves solving one problem at a time by focusing on one particular instance … This type of problem solving generally does not help prevent future harm from occurring. … Solving an adaptive problem is complex. … An adaptive solution to this problem involves encouraging a culture of safety. … · Use second-order problem solving to determine technical and adaptive solutions.

237. Facilitator Guide: Learning From Defects Through Sensemaking (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
     December 01, 2017 - Slide 3 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 4 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?

238. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73627/psn-pdf
     January 01, 2022 - The problem with 'My Five Moments for Hand Hygiene'. … The problem with ‘My Five Moments for Hand Hygiene’. … https://psnet.ahrq.gov/issue/problem-my-five-moments-hand-hygiene The “My Five Moments for Hand Hygiene … https://psnet.ahrq.gov/issue/problem-my-five-moments-hand-hygiene https://psnet.ahrq.gov/issue/my-five-moments-hand-hygiene-user-centred-design-approach-understand-train-monitor-and-report

239. Fairbanks, Rollin J. | Digital Healthcare Research
     digital.ahrq.gov/principal-investigator/fairbanks-rollin-j
     January 01, 2023 - Project Name Cognitive Engineering for Complex Decisionmaking & Problem Solving in Acute Care … Project Name Cognitive Engineering for Complex Decisionmaking & Problem Solving in Acute Care … Project Name Cognitive Engineering for Complex Decisionmaking & Problem Solving in Acute Care … Project Name Cognitive Engineering for Complex Decisionmaking & Problem Solving in Acute Care … Project Name Cognitive Engineering for Complex Decisionmaking & Problem Solving in Acute Care

240. Cost of medication-related problems at a university hospital. | PSNet
     psnet.ahrq.gov/issue/cost-medication-related-problems-university-hospital
     January 13, 2021 - Study Classic Cost of medication-related problems at a university hospital. Citation Text: Cost of medication-related problems at a university hospital. Schneider PJ; Gift MG; Lee YP; Rothermich EA; Sill BE Copy Citation Save Save to yo…