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psnet.ahrq.gov/issue/171-billion-problem-annual-cost-measurable-medical-errors
May 26, 2021 - Study
Classic
The $17.1 billion problem: the annual cost … The $17.1 Billion Problem: The Annual Cost Of Measurable Medical Errors. … The $17.1 Billion Problem: The Annual Cost Of Measurable Medical Errors.
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www.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/access/strategy6f-ondemand.html
April 01, 2023 - The Problem
6.F.2. The Intervention
6.F.3. Benefits
6.F.4. … The Problem
Individuals with non-urgent health problems typically have to schedule an in-person visit … nurses (RNs) who assist members who have questions or need advice related to a health condition or problem … call the advice line any time they or a family member are having symptoms of an illness or medical problem … the RN typically offers care management advice and health education related to the patient's health problem
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www.ahrq.gov/patient-safety/settings/hospital/vtguide/preface.html
March 01, 2016 - Measurement and Tracking
Hospital-Associated Venous Thromboembolism as a Public Health Problem … thrombosis (DVT), collectively known as venous thromboembolism (VTE), represent a major public health problem … Estimates vary widely, but the overall annual prevalence may be increasing. 2 VTE is primarily a problem
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www.ahrq.gov/hai/cusp/toolkit/index.html
July 01, 2018 - After the core principles of CUSP are taught, the knowledge can be applied to any safety problem. … Apply CUSP
After learning these core principles, users can apply them to the selected safety problem
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www.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/health-promotion-education/strategy6r-reminder-systems.html
March 01, 2020 - The Problem
6.R.2. The Intervention
6.R.2.a. Reminder Systems for Patients
6.R.2.b. … The Problem
Many patients do not receive important immunizations and other preventive services and … The Intervention
Two useful strategies for tackling this problem are:
Reminder Systems for Patients
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psnet.ahrq.gov/issue/drug-related-problem-outcomes-and-program-satisfaction-comprehensive-brown-bag-medication
September 23, 2020 - Review
Drug-related-problem outcomes and program satisfaction from a comprehensive … Drug-Related-Problem Outcomes and Program Satisfaction from a Comprehensive Brown Bag Medication Review … Drug-Related-Problem Outcomes and Program Satisfaction from a Comprehensive Brown Bag Medication Review … February 12, 2020
The problem with medication reconciliation.
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www.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/communication/strategy6i-shared-decisionmaking.html
April 01, 2023 - The Problem
6.I.2. The Intervention
6.I.3. Benefits of This Intervention
6.I.4. … The Problem
Although patients are far more informed than they were even 20 or 30 years ago, some people … One element of this problem is that patients often do not know enough about their treatment options to
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psnet.ahrq.gov/issue/applying-human-factors-engineering-address-telemetry-alarm-problem-large-medical-center
February 10, 2021 - Study
Applying human factors engineering to address the telemetry alarm problem in … Applying human factors engineering to address the telemetry alarm problem in a large medical center. … Applying human factors engineering to address the telemetry alarm problem in a large medical center. … February 10, 2021
Indication alerts to improve problem list documentation.
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psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
November 01, 2008 - Health Care–Acquired Urinary Tract Infection: The Problem and Solutions
Lindsay E. … Health Care–Acquired Urinary Tract Infection: The Problem and Solutions. PSNet [internet]. … Health Care–Acquired Urinary Tract Infection: The Problem and Solutions. PSNet [internet]. … So it's unclear which one is more likely to be a problem. … What do you think of the accreditation and regulatory approach to this problem?
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psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
March 01, 2007 - The Soil, Not the Seed: The Real Problem with Root Cause Analysis
Patrice Spath, BA, RHIT, and William … The Soil, Not the Seed: The Real Problem with Root Cause Analysis. PSNet [internet]. … The Soil, Not the Seed: The Real Problem with Root Cause Analysis. PSNet [internet]. … If we are correct, then the RCA tool is not the problem. … The Soil, Not the Seed: The Real Problem with Root Cause Analysis. PSNet [internet].
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digital.ahrq.gov/sites/default/files/docs/publication/r21hs022166-beebe-final-report-2016.pdf
January 01, 2016 - The Long Term Effectiveness of Telephone Intervention Problem Solving (TIPS) - Final Report … The long term effectiveness of Telephone Intervention Problem Solving (TIPS). … adherence but persons with SSDs have limited access to problem solving
interventions. … Problem-solving therapy: A positive approach to clinical
intervention. 3rd ed. … The long term effectiveness of Telephone Intervention Problem Solving (TIPS).
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psnet.ahrq.gov/issue/wicked-problem-patient-misidentification-how-could-technological-revolution-help-address
July 10, 2024 - Commentary
The wicked problem of patient misidentification: how could the technological … The wicked problem of patient misidentification: How could the technological revolution help address … The wicked problem of patient misidentification: How could the technological revolution help address
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www.ahrq.gov/sites/default/files/publications/files/goinghomeguide.pdf
April 01, 2010 - problem 4:
Notes about my medical problem 5:
Notes about my medical problem 6:
Notes about my medical … problem 7:
Notes about my medical problem 8:
Notes about my medical problem 9:
Notes about my … medical problem 10:
Notes about my medical problem 11:
Notes about my medical problem 12:
Notes … about my medical problem 13:
Notes about my medical problem 14:
Notes about my medical problem 15 … problem 18:
Notes about my medical problem 19:
Questions or Concerns:
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psnet.ahrq.gov/issue/teamwork-part-1-divided-we-fall-part-2-cursed-knowledge-building-culture-psychological-safety
August 02, 2015 - Fall; Part 2: Cursed By Knowledge: Building a Culture of Psychological Safety; and Part 3: The Not-My-Problem … Problem.
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digital.ahrq.gov/ahrq-funded-projects/using-electronic-medical-record-identify-and-screen-patients-risk-delirium
January 01, 2023 - Use the EMR to improve documentation of delirium in the problem list. … screening of at-risk patients and included clinician prompts to improve documentation of delirium in the problem … A comparison of diagnoses in the problem list found that, while not statistically significant, there
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www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-fac-notes.html
December 01, 2017 - Problem solving breaks down into two types: first-order problem solving and second-order problem solving … First-order problem solving is where we fix an immediate problem. … problem solving. … for first-order problem solving drops. … first-order problem solving.
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www.ahrq.gov/research/findings/nhqrdr/chartbooks/effectivetreatment/mhsa.html
June 01, 2018 - Process: Treatment for illicit drug use or alcohol problem. … In rural and remote areas, limited availability of skilled care providers is also a major problem. … People Who Received Treatment for Illicit Drug Use or an Alcohol Problem
People age 12 and over who … needed treatment for illicit drug use or an alcohol problem and who received such treatment at a specialty … 2013, only 10.9% of people age 12 and over who needed treatment for illicit drug use or an alcohol problem
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/mcc/mcc_infographic.pdf
April 02, 2025 - MCC IS A LARGE & GROWING PROBLEM
Almost one in three Americans lives with MCC. … The prevalence of MCC increases with age, however this
problem affects a large number of working aged … the elderly.
80%
49%
18%
7%
0-17 18-44 45-64 65+
% OF US POPULATION WITH MCC BY AGE
The problem … ages.
32% = 96.5 million people28%24%
2001 2006 2010
% OF US POPULATION WITH MCC OVER TIME
THE PROBLEM … RX
RX
To address the growing problem of MCC, the US healthcare system
must transform from a disease-specific
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/mcc/mcc_infographic_printable.pdf
April 02, 2025 - MCC IS A LARGE & GROWING PROBLEM
Almost one in three Americans lives with MCC. … The prevalence of MCC increases with age, however this
problem affects a large number of working aged … the elderly.
80%
49%
18%
7%
0-17 18-44 45-64 65+
% OF US POPULATION WITH MCC BY AGE
The problem … .
32% = 96.5 million people28% 24%
2001 2006 2010
% OF US POPULATION WITH MCC OVER TIME
THE PROBLEM … prescriptions
AVERAGE NUMBER OF PRESCRIPTIONS PER YEAR (new + refilled)
To address the growing problem
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/relations-diagram
January 01, 2023 - When a network of these relationships is present in a problem, the relations diagram becomes especially … When analyzing a complex problem to determine its causes.
How do I use this tool?
1.