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www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/postdischarge-doc.html
March 01, 2025 - If new problem since discharge: Had the patient: ___ Contacted or seen clinician? … _____________________ Medicine 2 :_________________________________________________________________ Problem … _____________________ 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/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/safetransitions/safetrans_apptaide.pdf
December 01, 2017 - 5
The Problem(s) I Need to Look For
I should… …if I have the following problem(s):
❑ Call 911
❑ … ❑ Call _________________
❑ Schedule follow-up appointment
I should… …if I have the following problem … Preparingfor Your Appointment
Before My Appointment
During My Appointment
My Medicine List
The Problem
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-89-adhd-behavior-section-2-attach-3.pdf
June 02, 2025 - page
6 Age Info Usually in the registration of face page
7 ADHD diagnosis date Cpt or visit or
problem … page
8 ADHD-focused evidence-based
behavior therapy prescribed
Note Discussion of diagnosis or problem
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digital.ahrq.gov/principal-investigator/sockolow-paulina
January 01, 2023 - Information Needs of Homecare Nurses During Admission and Care Planning
There's a problem … with the problem list: Incongruence of patient problem information across the home care admission. … There's a problem with the problem list: Incongruence of patient problem information across the home
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/red-toolkit/redtoolkitforms.docx
September 01, 2012 - Question or Problem with this Packet? … Call your Discharge Educator: (555) 555-2222
Serious health problem? Call Dr. … What To Do If a Problem Arises
CALLER: Before we hang up, I want to make sure that if a medical problem … Do you know what your main problem was? … Do you know what your main problem was?
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit5-10.html
November 01, 2014 - Horizon Hospital—Lakeview Healthcare
Based on the A3 tool, the project team:
Problem … action stipulated by the Value Stream Steering Committee in the project charter and redefines it as a problem … update data: Reviews and updates more detailed qualitative and/or quantitative data describing the problem
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www.ahrq.gov/hai/tools/surgery/modules/implementation/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
First-order problem solving
Recovers for one patient, but … Slide 5: Problem-Solving Goal
What is the long-term impact on patient safety culture? … Red arrow pointing down is captioned "First-order problem-solving addresses immediate need, but does … Green arrow pointing up is captioned "Second-order problem-solving addresses future needs and improves
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide46.html
October 01, 2014 - behavioral Therapies result in higher abstinence rates: (1) providing smokers with practical counseling (problem … behavioral therapies result in higher abstinence rates: (1) providing smokers with practical counseling (problem-solving
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psnet.ahrq.gov/node/47027/psn-pdf
June 19, 2018 - Overdiagnosis and overtreatment as a quality problem:
insights from healthcare improvement research. … Overdiagnosis and overtreatment as a quality problem: insights from healthcare improvement
research. … https://psnet.ahrq.gov/issue/overdiagnosis-and-overtreatment-quality-problem-insights-healthcare-
improvement-research … Tactics discussed include clear articulation of the problem and contributing factors, use of
theory-driven … https://psnet.ahrq.gov/issue/overdiagnosis-and-overtreatment-quality-problem-insights-healthcare-improvement-research
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digital.ahrq.gov/ahrq-funded-projects/information-needs-homecare-nurses-during-admission-and-care-planning
January 01, 2023 - with the problem list: Incongruence of patient problem information across the home care admission. … There's a problem with the problem list: Incongruence of patient problem information across the home … information across three phases of home care admission: there's a problem with the problem list. … Incongruence of patient problem information across three phases of home care admission: there's a problem … with the problem list.
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/curriculum/teamstepps-introduction-slides.pptx
June 02, 2025 - Is there a measurable problem? … Exercise
Introduction
What is the safety issue your organization is facing that is linked to a teamwork problem … How is this problem affecting patient safety and the staff on teams caring for them?
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/157-what-are-4-es.docx
October 01, 2024 - Misfortune’s Hospital, the staff assemble a team to focus on the MRSA problem. … They focus on communicating the problem. … The team quickly discovers staff are generally not aware of the MRSA problem at St. Miz. … Begin by outlining a problem statement. Determine as a team “why” this happened. … Then ask: “If this cause was corrected, is it likely that the problem would recur?”
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/video/debrief-emergency-dept-guide.pdf
June 02, 2025 - What was the main problem identified during the debrief, and what solution will the team
implement? … There were not enough team members at the onset of the code, and there was a problem notifying
the Code
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psnet.ahrq.gov/node/42587/psn-pdf
September 25, 2013 - Application of an engineering problem-solving
methodology to address persistent problems in patient … Application of an engineering problem-solving methodology to address persistent
problems in patient … https://psnet.ahrq.gov/issue/application-engineering-problem-solving-methodology-address-persistent- … This case study reports on a collaboration between engineers and safety professionals to
address the problem … https://psnet.ahrq.gov/issue/application-engineering-problem-solving-methodology-address-persistent-problems-patient
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psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph
February 26, 2025 - The second problem is that there tends not to be much follow-up. … The third problem is reinventing the wheel. … This is a problem that even the VA frequently confronts. … It seems to me that is to some extent the crux of the problem. … AW : The problem with general incident reporting has more to do with pattern recognition.
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psnet.ahrq.gov/node/836935/psn-pdf
April 13, 2019 - Root Cause Analysis: The Core of Problem Solving and
Corrective Action, Second Edition. … https://psnet.ahrq.gov/issue/root-cause-analysis-core-problem-solving-and-corrective-action-second-edition … https://psnet.ahrq.gov/issue/root-cause-analysis-core-problem-solving-and-corrective-action-second-edition
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psnet.ahrq.gov/node/50849/psn-pdf
January 29, 2020 - prescription-drug-overload-critics-fighting-curb-epidemic-medication-side-effects
https://psnet.ahrq.gov/issue/old-and-overmedicated-real-drug-problem-nursing-homes … https://psnet.ahrq.gov/issue/drug-related-problem-outcomes-and-program-satisfaction-comprehensive-brown-bag-medication … https://psnet.ahrq.gov/issue/medication-overload-americas-other-drug-problem
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psnet.ahrq.gov/node/39521/psn-pdf
May 12, 2010 - Confusion about epinephrine dosing leading to iatrogenic
overdose: a life-threatening problem with a … Confusion about epinephrine dosing leading to iatrogenic overdose: a
life-threatening problem with a … psnet.ahrq.gov/issue/confusion-about-epinephrine-dosing-leading-iatrogenic-overdose-life-
threatening-problem … near misses due to incorrect dosing of epinephrine and
gives examples of potential solutions to the problem … psnet.ahrq.gov/issue/confusion-about-epinephrine-dosing-leading-iatrogenic-overdose-life-threatening-problem
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/morningbriefing.doc
June 02, 2025 - Conducting a Morning Briefing
Problem statement: Physicians can improve communication with nursing staff … Specific Things To Consider
Problem Identified
Person Assigned To Followup
Action Taken
Patient
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meps.ahrq.gov/data_files/publications/st274/stat274.shtml
December 01, 2009 - Adults ages 25-44 were more than twice as likely as adults age 65 and over to feel it was a big problem … Uninsured adults ages 18-64 were more likely to report that accessing a specialist was a big problem … Moreover, those with only public insurance were more likely to report it was a big problem (15.8 percent … A big problem, A small problem, Not a problem. … , by age, 2007
Needed to see a specialist Big problem*
All Adults 18+ 35.8% 7.6%
18