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psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-acute-hospital-care-units
April 26, 2023 - monitoring on general care units is the alarm problem . … He came to the team and said, “I have this problem in the inpatient setting, let’s do something about … Another aspect of the alarm problem is distraction. … Finally, there’s the literature on alarm fatigue, which gets confused with the alarm problem, because … You’re trying to address the problem of severe and sustained events.
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www.ahrq.gov/hai/cauti-tools/archived-webinars/assess-adapt-transcript.html
December 01, 2017 - Now, there are many solutions that have been proposed to this problem. … There are considerable ways to attack this problem and it can be difficult to know exactly what to do … Second-order problem solving, which takes it to the next step, this is fixing the system factors that … allowed the problem to occur. … I don't have to tell you that we in health care are very, very good at first-order problem solving.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/assess-adapt-transcript.doc
June 03, 2014 - Now, there are many solutions that have been proposed to this problem. … There are considerable ways to attack this problem and it can be difficult to know exactly what to do … Second-order problem solving, which takes it to the next step, this is fixing the system factors that … allowed the problem to occur. … I don’t have to tell you that we in health care are very, very good at first-order problem solving.
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psnet.ahrq.gov/perspective/what-weve-learned-about-leveraging-leadership-and-culture-affect-change-and-improve
March 01, 2017 - Culture change inevitably occurs slowly, through cycles of action and interpretation.( 8 ) Problem solving … A focus on problem solving also reinforces the learning orientation that is core to a culture of safety … while building problem-solving capacity. … Often considered "the problem," resistance may be more productively and accurately viewed as the key … 1, 2013
Perspective
How to Identify and Manage Problem
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/red-toolkit/dxpages.docx
April 07, 2025 - Pages
Noncardiac Chest Pain
Noncardiac chest pain is pain that is not caused by a heart problem
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www.ahrq.gov/talkingquality/translate/compare/order.html
November 01, 2018 - However, this problem can be mitigated in Web-based reports; for example:
The site could permit a … Advantages to Ordering Within Cost Tiers
This approach avoids a major problem with presenting cost
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/murray-md-et-al-1998
January 01, 1998 - Pharmacists also spent 34.0 percent less time filling prescriptions, 45.8 percent more time in problem-solving … After computer-based outpatient prescription writing, pharmacists spent 45.8 percent more of their time problem-solving … Owing largely to this time spent problem solving, the time spent filling prescriptions decreased by 34 … treatments and advising patients decreased by 3.3 percent, a considerably smaller effect than that seen with problem
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/workflow-analysis-qi.pdf
February 01, 2005 - Administration
Primary Care Practice
Core and Supporting Processes
Processes
Works
Well
(1)
Small
Problem … (2)
Real
Problem
(3)
Totally
Broken
(4)
Cannot
Rate
(5)
We're
Working On It
(6)
Source of Patient
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www.ahrq.gov/sites/default/files/publications/files/ena-slides.pdf
September 01, 2015 - When looking at this from a CAUTI perspective, some relevant questions are:
Problem identification … • Questions around ownership: Whose problem is it? … So whose problem is urinary catheterization anyway? Emergency nurses? Inpatient nurses? Providers? … Assumptions around catheter use and the issues they create become the problem of the institution, not … ” and “my problem” into “our
problem.”
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/guides/ena-slides.pdf
September 01, 2015 - When looking at this from a CAUTI perspective, some relevant questions are:
Problem identification … • Questions around ownership: Whose problem is it? … So whose problem is urinary catheterization anyway? Emergency nurses? Inpatient nurses? Providers? … Assumptions around catheter use and the issues they create become the problem of the institution, not … ” and “my problem” into “our
problem.”
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www.ahrq.gov/hai/cusp/toolkit/content-calls/assertion.html
April 01, 2013 - Be hard on the problem, not on the people. … It’s important to note, though, that this question has the notion of a problem, and so you are speaking … Jill Marstellar: Yes, I mean it’s definitely a problem, and I do think that you hit the nail on the … Jill Marstellar: I think you are right that it’s a problem. … It’s a tough problem to know how to try to address it.
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/heart-health/evidencenow-story.pdf
September 01, 2021 - EXCELLENCE IN
PRIMARY CARE RESEARCH
EvidenceNOW: A Model for Heart Health and Beyond
1
The Problem … evidencenow/index.html
http://www.ahrq.gov
EvidenceNOW: A Model for Heart Health and Beyond
The Problem
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/workforce-financing/case_example_7.pdf
October 01, 2016 - The most common
behavioral health problem is substance use, with extremely high use of narcotics, alcohol … Reviewing and
reconciling problem list
Providers, who keep a list of problem patients with high needs … These staff are
building expertise in patient engagement, outreach, problem-solving about
barriers … Helping patients get medications is a significant problem at Cherokee. … Accessing subspecialty care, and especially transportation for care, is a huge problem for
Cherokee
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/hp/Adult_Med_Eng_HP51_2152a.pdf
October 01, 2020 - A personal doctor is the one you would talk
to if you need a check-up, want advice
about a health problem … In the past 6 months, did you get health
care 3 or more times for the same condition
or problem? … Is this a condition or problem that has
lasted for at least 3 months?
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psnet.ahrq.gov/issue/remembering-learn-overlooked-role-remembrance-safety-improvement
February 28, 2024 - September 13, 2023
The problem with incident reporting. … November 6, 2015
The problem with checklists.
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digital.ahrq.gov/ahrq-funded-projects/identifying-sepsis-phenotypes-associated-antibiotic-resistant-pathogens-using
August 01, 2024 - It is a major health problem because it is difficult to diagnose and treat effectively, often requiring … This overuse contributes to the growing problem of antibiotic resistance, where bacteria evolve to become
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digital.ahrq.gov/sites/default/files/docs/page/ADAMS_3_I.ppt
January 01, 2013 - Introduction
The Problem
HealthAlliant
Solution
Process
Next Steps
(c) 2003 HealthAlliant, Inc. … Introduction
The Problem
HealthAlliant
Solution
Process
Next Steps
(c) 2003 HealthAlliant, Inc. … Introduction
The Problem
HealthAlliant
Solution
Process
Next Steps
(c) 2003 HealthAlliant, Inc. … All rights reserved
Free Ride Problem:
100% of the cost, X% of the return
Drives down ROI … Introduction
The Problem
HealthAlliant
Solution
Process
Next Steps
(c) 2003 HealthAlliant, Inc.
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digital.ahrq.gov/sites/default/files/docs/survey/stage3-mu-practice-manager-survey.pdf
June 16, 2021 - information,
Care plan field, including goals and
instructions, Care team, Reason for referral,
Current problem … Mix of
electronic
and mail/fax
Predominantly
electronic
Key Patient Clinical
Data (e.g., problem … Mix of
electronic
and mail/fax
Predominantly
electronic
Key Patient Clinical
Data (e.g., problem … Mix of
electronic
and mail/fax
Predominantly
electronic
Key Patient Clinical
Data (e.g., problem … Mix of
electronic
and mail/fax
Predominantly
electronic
Key Patient Clinical
Data (e.g., problem
-
www.ahrq.gov/patient-safety/resources/learning-lab/optimizing-safety-long-desc.html
June 01, 2020 - Develop a systematic method to study patient safety using a stepwise approach of problem analysis through … electronic medical record (EMR)—provides easily recognizable visual cues (e.g., color-coding) to avoid this problem
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psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
September 01, 2014 - Christopher Moriates, MD In 2016, 63 million adults aged 19 to 64 (34%) reported having a cost-related problem … scores and more rehospitalizations.( 3 ) In addition, cost-related medication nonadherence is a common problem … when the primary care provider finally called the insurance company, he was able to quickly resolve a problem … Clinicians and health care systems should address this problem systematically, just as they do with other … Same Author(s)
Perspective
Overuse as a Patient Safety Problem