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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/observation/observation.pptx
May 01, 2017 - Supervisor can report on gaps in daily huddle and use problem-solving methods to reduce the gaps. … jpeg
image1.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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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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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
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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/ncepcr/tools/PCMH/pcpf-module-21-leadership.pdf
September 01, 2015 - This involves the leader identifying
the problem, identifying the solution to the problem, and then … Examples include, “What is your ideal solution to this problem?” … problem and determine whether it is truly a “problem” or merely a misinterpretation
of a situation … Think of a problem you have tried (and failed) to fix multiple times. … leaders then must gather information on the problem.
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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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psnet.ahrq.gov/node/33687/psn-pdf
August 01, 2009 - prevent problem recurrence. … These behaviors, called second-
order problem solving, include communicating about the problem to people … Second-order problem
solving is necessary for lasting improvement.(12)
Second-order problem solving … Real-time problem solving is examining a
specific problem as close as possible to the location and time … Using real-time problem solving to eliminate central line
infections.
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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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psnet.ahrq.gov/node/47039/psn-pdf
September 12, 2018 - Overdiagnosis in primary care: framing the problem and
finding solutions. … Overdiagnosis in primary care: framing the problem and finding solutions. … https://psnet.ahrq.gov/issue/overdiagnosis-primary-care-framing-problem-and-finding-solutions
Overdiagnosis … https://psnet.ahrq.gov/issue/overdiagnosis-primary-care-framing-problem-and-finding-solutions
https:/ … /psnet.ahrq.gov/issue/overdiagnosis-and-overtreatment-quality-problem-insights-healthcare-improvement-research
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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/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/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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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/patient-safety/settings/hospital/match/chapter-2.html
July 01, 2022 - The charter will be a dynamic document that encompasses the following elements:
Problem statement … Problem Statement. … A problem statement is a concise description of the issues that need to be addressed by the team and … A good problem statement should consider the nature of the problem and how it impacts patient care. … The team should establish goals and objectives that directly relate to the above problem statement.
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www.ahrq.gov/es/patient-safety/settings/hospital/match/chapter-2.html
July 01, 2022 - The charter will be a dynamic document that encompasses the following elements:
Problem statement … Problem Statement. … A problem statement is a concise description of the issues that need to be addressed by the team and … A good problem statement should consider the nature of the problem and how it impacts patient care. … The team should establish goals and objectives that directly relate to the above problem statement.
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cds.ahrq.gov/sites/default/files/cds/artifact/27811/Test-Cases.xlsx
October 28, 2021 - Rule Recommendations are mutually exclusive across rules (at most one given) Has Persistent Asthma on Problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem
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cds.ahrq.gov/sites/default/files/cds/artifact/27801/Test-Cases.xlsx
October 28, 2021 - Rule Recommendations are mutually exclusive across rules (at most one given) Has Persistent Asthma on Problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem
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cds.ahrq.gov/sites/default/files/cds/artifact/27796/Test-Cases.xlsx
October 28, 2021 - Rule Recommendations are mutually exclusive across rules (at most one given) Has Persistent Asthma on Problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem
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cds.ahrq.gov/sites/default/files/cds/artifact/27781/Test-Cases.xlsx
October 28, 2021 - Rule Recommendations are mutually exclusive across rules (at most one given) Has Persistent Asthma on Problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem