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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module3/module3_pu-bestpractices_slides.pptx
April 02, 2025 - Problem 2. Potential Problem 3. No Apparent Problem
© Barbara Braden and Nancy Bergstrom, 1988.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/system/delivery-system-initiative/mccannon/mccannon.ppt
February 17, 2011 - Slide 1
The Spread Problem
The Challenge and Promise of Delivery System Research: A Meeting of AHRQ … Centers for Medicare and Medicaid Services
February 17, 2011
*
Ground to Cover
The Spread Problem … effectiveness on a smaller scale
Degree of awareness
Degree of confidence
*
*
Framing
Problem
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digital.ahrq.gov/location/usa-tn-knoxville
January 01, 2023 - TN, Knoxville
The Long Term Effectiveness of Telephone Intervention Problem … Solving (TIPS)
Description
This project evaluated the impact of the “Telephone Intervention Problem
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psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient
February 21, 2020 - The problem of EHR “mis-routing” has been previously identified as a root cause of medical errors and … , in one review of IT-related malpractice claims, was identified as a contributing problem in about 10% … Harnessing the power of problem representation can help us continue to think critically about our patients … Careful constructions of problem presentations, particularly in children with chronic medical conditions … The importance of early problem representation during case presentations.
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digital.ahrq.gov/organization/northwestern-university
January 01, 2023 - implemented indication alerts, which occur when an ordered or prescribed medication lacks a corresponding problem … on the patient’s problem list. … The research found a significant increase in problem placement rates, a modest increase in order abandonment
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www.ahrq.gov/hai/cusp/toolkit/content-calls/conflict-resolution-slides/slides.html
October 01, 2014 - a circular chart showing the steps:
Get Person's Attention leading to Express Concern then State Problem … care
Depersonalize the conversation
Actively avoid being perceived as judgmental
Be hard on the problem … CONFRONTATION —Meet the problem head on (win-win)
Return to Contents
Slide 13.
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/5-determining-focus/cahps-ambulatory-care-guide-section-5.pdf
May 01, 2017 - Considerations include how widespread the problem is, how different your score is from
others (i.e., … Articulating the issue in writing helps
you formalize the problem and describe it completely. … It also helps everyone on the
improvement team focus on the same problem. … happens and write the answer down below the
problem. … All patients who report a problem scheduling appointments.
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www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyuptp.html
July 01, 2023 - In-depth reviews assessed practices on the following domains:
How important is the problem? … All practices were then summarized on the following domains: scope of the problem, strength of evidence
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/DxSftyRpt-Updated-2022.pdf
January 01, 2022 - this office have enough time to review the relevant
information related to the patient’s presenting problem … this office have enough time to review the relevant
information related to the patient’s presenting problem … this office have enough time to review the relevant information related to the patient’s
presenting problem … 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
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www.ahrq.gov/sites/default/files/wysiwyg/topics/defining-diagnostic-error-a-scoping-review.pdf
April 27, 2022 - error as, “the failure to (a) establish
an accurate and timely explanation of the patient’s health problem … ; (2) communication, confusion about the explanation of
the health care problem; and (3) timeliness, … it took too long to receive
an explanation for a health care problem. … and “Has a
physician ever misdiagnosed your endometriosis as a
mental health problem (before you were … NASEM1 The failure to (a) establish an accurate and timely explanation of the patient’s health problem
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/research-centers/new_model_thinking.pdf
February 01, 2014 - PREVENTION
A New Model of Thinking in Clinical Preventive Services
The Harms of Screening: an Unseen Problem … PREVENTION A New Model of Thinking in Clinical Preventive Services
The Harms of Screening: an Unseen Problem
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/data
January 01, 2023 - Kepner-Tregoe Matrix
Description
A Kepner-Tregoe matrix is used to find causes of a problem … This allows you to compare what the problem is, with what it is not, illuminating distinctive features … of the problem and pointing out its potential causes.
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www.ahrq.gov/funding/process/review/peerproc.html
July 01, 2021 - Significance: Does this study address an important problem? … Does the applicant acknowledge potential problem areas and consider alternative tactics? … Importance and Impact (if applicable): What are the importance of the problem addressed and the potential … impact of the solution of this problem on health or on health care delivery?
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/170-cusp-science-safety-notes.docx
October 01, 2024 - Slide 4
How Can Safety Be Such a Big Problem? … When creating a team to address a safety problem, it’s important to remember that diverse groups offer … The CUSP team applies systems thinking, seeking to understand the why behind the problem without blame … Show a reluctance to simplify both the problem and the solution. … When you are problem solving, evaluate feasibility.
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/plan-do-check-act-cycle
January 01, 2023 - For problem solving.
For continuous improvement.
To develop a design. … Maintains order during problem solving.
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www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/ptoutcome-mail.html
March 01, 2025 - hospital stay, the doctors and nurses may have told you the name of your primary diagnosis or main problem … Do you know what your main problem was? … ____________________________ If YES, Can you please list the name of your primary diagnosis or main problem
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs017196-jack-final-report-2011.pdf
January 01, 2011 - problem; potential problem that needs followup;
problem, needs response in a timely way. … become a more serious problem 4 12.90
Alert Rating: Potential problem that needs followup 6 19.35 … (if alert rated as a potential problem or problem
needing timely response) n=13: Neither preventable … alert rated as a potential problem or problem needing
timely response) n=13: Procedure related injury … problem or problem needing
timely response) n=13: Therapeutic-error (AE due to treatment, other than
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www.ahrq.gov/hai/cusp/modules/engage/exec-notes.html
December 01, 2012 - One method of engagement is sharing stories about patients affected by this problem and estimating the … number of patients who could be harmed as a result of this problem. … This technical solution to their unit-based problem—the line cart and supply checklist—increased staff … Verify the decisionmaking, conflict management, and problem-solving processes are clear, and
Ensure … (Technical)
Are decisionmaking, problem-solving, and conflict management processes understandable?
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psnet.ahrq.gov/issue/effective-followership-standardized-algorithm-resolve-clinical-conflicts-and-improve-teamwork
March 13, 2013 - Retained guidewires in the Veterans Health Administration: getting to the root of the problem … Related Resources
Speaking up and taking action: psychological safety and joint problem-solving … Fall; Part 2: Cursed By Knowledge: Building a Culture of Psychological Safety; and Part 3: The Not-My-Problem … Problem.
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/nurse-role-dxsafety-apa.html
September 01, 2022 - Formulate, or contribute to, an accurate problem representation expressed in a concise summary statement … How would you summarize the patient’s problem and your findings? … How would you communicate the patient’s problem and your findings to the diagnostic team?