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psnet.ahrq.gov/node/73208/psn-pdf
May 05, 2021 - accuracy-practitioner-estimates-probability-diagnosis-and-after-testing
https://psnet.ahrq.gov/issue/overdiagnosis-and-overtreatment-quality-problem-insights-healthcare-improvement-research … delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism
https://psnet.ahrq.gov/perspective/overuse-patient-safety-problem
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs023837-gurses-final-report-2021.pdf
January 01, 2021 - The problem list is a required component of certified EHR systems. … We determined the number of active problem
list items at arrival and the number of problem list actions … Across all encounters, 975 problem list actions were executed. … Almost all (98.8%) recorded problem lists
actions were the addition of items. … Characterizing the Utilization of the
Problem List for Pediatric Trauma Care.
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psnet.ahrq.gov/node/42231/psn-pdf
June 18, 2013 - to predict problematic behavior by clinicians and point the way toward system-
level solutions for problem … /disciplinary-action-medical-boards-and-prior-behavior-medical-schools
https://psnet.ahrq.gov/issue/problem-doctors-there-system-level-solution … https://psnet.ahrq.gov/issue/problem-doctors-there-system-level-solution
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psnet.ahrq.gov/node/61018/psn-pdf
October 14, 2020 - association-current-opioid-use-serious-adverse-events-among-older-adult-
survivors-breast
Chronic opioid use for noncancer pain is a well-established patient safety problem … web-mm/pains-chronic-opioid-usage
https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
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digital.ahrq.gov/sites/default/files/docs/survey/telemedicine-and-non-telemedicine-visit-experience-interview-guides.pdf
June 16, 2021 - ___ Wait till the 1st available appointment at my child’s doctor’s office
___ Wait to see if the problem … How confident were you that this child’s problem was appropriate for telemedicine? … How confident were you that this child’s problem was appropriate for telemedicine, on a scale of 1-5 … How confident were you that this child’s problem was appropriate for telemedicine, on a scale of 1-5 … How confident were you about your diagnosis compared to any in-person visit for this type of problem?
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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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psnet.ahrq.gov/issue/surgical-fire-united-states-2000-2020
March 03, 2021 - September 22, 2021
Indication alerts to improve problem list documentation. … June 9, 2021
Crisis recovery in surgery: error management and problem solving in safety-critical … Related Resources
Patient falls in the operating room: why is this still a 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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psnet.ahrq.gov/node/44974/psn-pdf
April 12, 2019 - medicare-letters-curb-overprescribing-controlled-substances-had-no-
detectable-effect
Overprescribing of opioids is a serious and worsening problem … opioid-prescribing-after-nonfatal-overdose-and-association-repeated-overdose-cohort-study
https://psnet.ahrq.gov/perspective/overuse-patient-safety-problem
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digital.ahrq.gov/ahrq-funded-projects/value-new-drug-labeling-knowledge-e-prescribing
January 01, 2023 - Standards and Classifications
Medication and indication linkage: a practical therapy for the problem … Medication and indication linkage: a practical therapy for the problem list? … Support System , Electronic Prescribing , Standards and Classifications
Evaluation of the VA/KP problem … Evaluation of the VA/KP problem list subset of SNOMED as a clinical terminology for electronic prescription
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effectivehealthcare.ahrq.gov/sites/default/files/facilitation-webcast-slides.pptx
June 13, 2013 - Asks the public to be a problem-solver
Problem is policy-oriented, complex, multi-faceted
Requires accurate … First and foremost, deliberation asks people to be problem-solvers. … Addressing the problem requires trade-offs that speak to social value judgments, e.g.:
Concerns about … of the growing rate of Obesity and ways to tackle the problem
Passive P
The Participants need to do … to know about the facilitation process to tackle this problem.
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integrationacademy.ahrq.gov/sites/default/files/2020-07/MDHAQ.pdf
January 01, 2020 - How much of a problem has UNUSUAL fatigue or tiredness been for you OVER THE PAST WEEK? … FATIGUE IS
NO PROBLEM
{ { { { { { { { { { { { { { { { { { { { {
0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 … 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10
FATIGUE IS A
MAJOR PROBLEM
10. … �Yes A fall, broken bone, or other accident or trauma
�No �Yes An important new symptom or medical problem
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psnet.ahrq.gov/node/46724/psn-pdf
April 12, 2019 - A PSNet perspective highlighted opioid overdose as a major patient
safety problem. … cdc-guideline-prescribing-opioids-chronic-pain-united-states-2016
https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
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psnet.ahrq.gov/node/848125/psn-pdf
April 26, 2023 - could be attributed to inaction or the lack of recognition of deterioration.1,2 In response to this
problem … Addressing the Alarm Problem
One hurdle that organizations face in implementing any type of continuous … monitoring on general care units
is the alarm problem. … In addition to the alarm problem, the heavily documented phenomena of alarm fatigue shows that clinicians … Understanding the "alarm problem" associated with
continuous physiologic monitoring of general care
-
digital.ahrq.gov/research-method/chart-review
January 01, 2023 - for Lung Cancer Screening
Cognitive Engineering for Complex Decisionmaking & Problem … Cognitive Engineering for Complex Decisionmaking & Problem Solving in Acute Care - Final Report. … Hettinger, Aaron Zachary
Project Name
Cognitive Engineering for Complex Decisionmaking & Problem
-
psnet.ahrq.gov/node/42367/psn-pdf
July 24, 2013 - psnet.ahrq.gov/issue/risk-management-obstetrics-and-gynaecology
https://psnet.ahrq.gov/issue/recurring-problem-retained-swabs-and-instruments … https://psnet.ahrq.gov/issue/recurring-problem-retained-swabs-and-instruments
https://psnet.ahrq.gov
-
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
-
effectivehealthcare.ahrq.gov/sites/default/files/pdf/medication-therapy-management-1_research.pdf
July 01, 2012 - • A problem with the drug dose being taken by the patient. … in
the numbered box below the problem and cause codes. … of the methods
used for resolving the drug related problem. … drug related problem. … Problem
(Modified PCNE Problem Code)
Yes?
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psnet.ahrq.gov/issue/developing-common-language-evaluation-questions-quality-and-safety-improvement
September 27, 2016 - February 10, 2021
Applying human factors engineering to address the telemetry alarm problem … The sinks can make the problem worse. … December 9, 2009
Quality of medication use in primary care—mapping the problem, working
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digital.ahrq.gov/sites/default/files/docs/page/AHRQPlenary6.05.pdf
November 01, 2004 - Medical Progress Over Half a CenturyMedical Progress Over Half a Century
Problem Goes BeyondProblem … It is
the problem you tackled after all the high-tech,
profitable and sexy stuff was taken care of
(which … overrated impact on
patient safety
– It has plenty of baggage, but not the root cause
of our safety problem … Lack of accountability: a big problem
– There are some bad doctors and nurses,
notwithstanding “no … Pre-IOM EraPre-IOM Era
Patient safety not in the vocabulary
Little understanding of nature of
problem