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Total Results: 7,956 records

Showing results for "problem".

401. The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety | PSNet
     psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
     October 01, 2009 - The problem of patient safety needed to be brought into sharper focus if it was going to receive the … The first, typified by To Err Is Human , involves broad, analytical pieces that tackle the general problem … But when the state inspectors went into the hospital, they discovered that it was not a problem with … Then, not only is the problem what actually happened, but the problem is that you tried to cover it up … problem.

402. Never Events | PSNet
     psnet.ahrq.gov/primer/never-events
     June 15, 2024 - However, when Never Events occur, they are devastating to patients and may indicate a fundamental safety problem … April 4, 2024 The problem with 'never events'. … September 4, 2024 Patient falls in the operating room: why is this still a problem in 2024?

403. Procedure Manual Section 5. Modeling | United States Preventive Services Taskforce
     www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/procedure-manual/procedure-manual-section-5-modeling
     July 05, 2017 - The USPSTF must determine when it is possible in the overall process to define the decision problem/objective … The "Decision Problem/Objective" is a template approach ( Appendix XIII ) that outlines the modeling … What is the decision problem/objective to be addressed through decision modeling ? … this is an attractive concept, it is uncommon that an existing decision model will match the decision problem … Searching for existing decision models is most efficient if it is focused on the specific decision problem

404. Retained Surgical Items: Definition and Epidemiology. | PSNet
     psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
     September 15, 2024 - RFO or RFB is not the result of medical error, whereas an RSI is a multi-stakeholder patient safety problem … discrepancies had not yet been resolved, and in fact, the team was using best practices to solve the problem … Increased appreciation of the problem of retained vaginal sponges and other items (e.g., vaginal packing … Needles are the most frequently miscounted surgical item, but their relative contribution to the problem … December 15, 2024 Patient falls in the operating room: why is this still a problem

405. Tamblyn R et al. 2003 "The medical office of the 21st century (MOXXI): effectiveness of computerized decision-making support in reducing inappropriate prescribing in primary care." | Digital Healthcare Research
     digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/tamblyn-r-et-al-2003
     January 01, 2003 - were identified by the CDS software, the physician received an alert that identified the nature of the problem … Each alert message identified the nature of the problem and possible consequences and suggested alternative … The only substantially higher discontinuation rate for a specific prescribing problem was for drug interactions

406. Lambert, Bruce | Digital Healthcare Research
     digital.ahrq.gov/principal-investigator/lambert-bruce
     January 01, 2023 - Errors With Indication Alerts in CPOE Systems Indication alerts to improve problem … Indication alerts to improve problem list documentation.

407. AHRQ Webinar - Digital Healthcare Innovations to Engage and Empower Patients in Their Care - Q&As (pdf file)
     digital.ahrq.gov/sites/default/files/docs/digital-healthcare-innovations-engage-empower-qas-10112023.pdf
     October 12, 2023 - ANSWER: We were anticipating that it could be a problem and budgeted for data plans. … ANSWER: It is becoming less of a problem than it has been over time, as you do not run into many people … This is much less of a problem than we might think. … This just was not such a problem.

408. Sequist T et al. 2005 "A randomized trial of electronic clinical reminders to improve quality of care for diabetes and coronary artery disease." | Digital Healthcare Research
     digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/sequist-t-et-al-2005
     January 01, 2005 - This algorithm searched all laboratory and radiology results as well as the problem list, medication … patient summary screen ... alongside other pertinent information such as the patient medication list and problem … "This electronic record allows physicians to maintain patient problem, medication, and allergy lists

409. Reducing the Safety Hazards of Monitor Alert and Alarm Fatigue | PSNet
     psnet.ahrq.gov/perspective/reducing-safety-hazards-monitor-alert-and-alarm-fatigue
     May 01, 2016 - monitor alarms are false or clinically insignificant.( 2-5 ) Hospitals are struggling to address this problem … RW : When you first began investigating this, did you have a theory as to what the problem was, and did … RW : That's just such a wonderful story that captures the essence of the problem. … BD : Alarm fatigue is probably a much bigger problem on a general medical floor than in the ICU. … September 1, 2016 Insights into the problem of alarm fatigue with physiologic monitor

410. Electronic Records to Improve Care for Children - 2009 | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/electronic-records-improve-care-children/annual-summary/2009
     January 01, 2009 - Clinicians were provided with quarterly summaries of their care practices relative to patient problem … Impact and Findings: The project confronted a serious chronic health problem (asthma) in a particularly … quarters, health care providers in participating centers improved the frequency of recording asthma on the problem

411. Good Catch in the Operating Room | PSNet
     psnet.ahrq.gov/web-mm/good-catch-operating-room
     August 27, 2017 - An acronym for key expressions containing code words signaling a potential urgent safety problem, the … " or "This is a S afety issue," it indicates that the member wants to "stop the line" to address a problem … Third, she stated what she felt was the perceived problem of unrecognized hemorrhage. … Fourth, she offered her solution by suggesting to stop the procedure and figure out the problem. … Take-Home Points The CUS Tool can help alert other team members to a safety problem and should prompt

412. Trauma (Physical) | Digital Healthcare Research
     digital.ahrq.gov/medical-condition/trauma
     January 01, 2024 - Diverse Primary Care Practices (ASPIRE) Characterizing the utilization of the problem … Characterizing the utilization of the problem list for pediatric trauma care.

413. Feb-2017-Cholesterol-Wg-Notes (doc file)
     cds.ahrq.gov/sites/default/files/workgroups/221/feb-2017-cholesterol-wg-notes.docx
     January 01, 2017 - . · Using diagnoses documented on the problem list alone may compromise sensitivity, as problem lists … However, there is significant movement to improve problem list maintenance. … Long lookback times exacerbate this problem. · Population management CDS artifacts would be innovative

414. Understanding Clinical Information Needs and Health Care Decision Making Processes in the Context of Health IT (R01) | Digital Healthcare Research
     digital.ahrq.gov/funding-mechanism/understanding-clinical-information-needs-and-health-care-decision-making-processes
     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

415. Define Your Vision | The Academy
     integrationacademy.ahrq.gov/products/playbooks/behavioral-health-and-primary-care/planning-for-integration/define-your-vision
     July 01, 2024 - Find out where you, your team, and other staff fall on the continuum: If: We don't see a big enough problem … If: We see a big enough problem but don't understand it, know what to do about it, or know what changes … If: We see a problem, have ideas for what to do about it, want to move forward in some way at some time … Midlevel operational leaders play a role in acquiring resources and problem-solving during implementation

416. Harm From Alarm Fatigue | PSNet
     psnet.ahrq.gov/web-mm/harm-alarm-fatigue
     February 14, 2018 - This patient's telemetry device warned of this problem with "low voltage" alarms. … alarms that indicate poor signal quality (e.g., a low battery in a telemetry device, an electrode problem … Take-Home Points Alarms should never be completely silenced; rather, clinical staff should problem-solve … Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational … October 10, 2012 Insights into the problem of alarm fatigue with physiologic monitor

417. Value of New Drug Knowledge for e-Prescribing (pdf file)
     digital.ahrq.gov/sites/default/files/docs/publication/r01hs015377-schadow-final-report-2008.pdf
     January 01, 2008 - The FDA has adopted the Veteran Administration and Kaiser Permanente (VA/KP) Problem List Subset of … medication order entry application which we had created based on these standards includes an allergy list, problem … For example, we showed how RxNorm, NDFRT, and SNOMED-CT can be used to make inferences about the Problem … Medication and indication linkage: a practical therapy for the problem list? … Evaluation of the VA/KP problem list subset of SNOMED as a clinical terminology for electronic prescription

418. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867497/psn-pdf
     February 26, 2025 - could not have been true) in 40 of the 46 (87%) retained sponge cases.4 There must have been some problem … In these cases, counting identified a problem but communication failed. … This problem is called normalization of deviance and may drive unhealthy cultural responses (e.g., “ … false positive counts are exceedingly common in the management of suture needles.7 This is a practice problem … Retained surgical items: overview of a persistent problem in health care.

419. Assessing Readiness, Achievement & Impact of Stage 3 Care Coordination Criteria - Final Report (pdf file)
     digital.ahrq.gov/sites/default/files/docs/publication/r18hs022674-adler-milstein-final-report-2014.pdf
     January 01, 2014 - Assist with treatment and management of the patient's health problem Help the patient overall … Clarify the level of detail required for problem list reconciliation. … Consider specifying that problem list reconciliation may be performed at a less granular level than … Second, practices differed in whether or not they included acute problems on the problem list and short … This additional level of detail often reduced ambiguity during problem list reconciliation when more

420. Managing disruptive behaviors in the health care setting: focus on obstetrics services. | PSNet
     psnet.ahrq.gov/issue/managing-disruptive-behaviors-health-care-setting-focus-obstetrics-services
     February 03, 2010 - August 27, 2012 Perspective How to Identify and Manage Problem … September 1, 2010 Perspective How to Identify and Manage Problem