-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.206_slideshow.ppt
October 01, 2009 - assuring follow-up
Meets with physician–subject of complaint
Physicians often wanted to talk about problem … then focus on inappropriate reaction
Letter to credentials file chronicling results of meetings
A Problem … life or imminent danger, but disruptive behavior rarely rises to this level of threat
More commonly, problem … suspension of privileges, MD has right to “fair hearing”
Extremely protracted (often years) process
The Problem
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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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psnet.ahrq.gov/sites/default/files/2019-11/webmm_spotlight_suicide_risk_assessment.pdf
January 01, 2019 - Prioritizing Suicidal Ideation and Attempts on Medical
History/Problem List
3. … Prioritizing Suicidal ideation/ Attempt on Medical History/ Problem List
• Suicidal ideation or attempt … should be entered on Problem List
– Include an appropriate plan that carries over onto Progress Note … – More likely to be seen by nursing staff and primary medical teams
– Suicide item on problem list … a continuum of behavioral health and community services
30
Key Quality Improvement Actions
• Problem
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psnet.ahrq.gov/issue/national-patient-safety-foundation-agenda-research-and-development-patient-safety
June 16, 2011 - May 27, 2011
Incident reporting system does not detect adverse drug events: a problem … 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/sites/default/files/docs/workflowtoolkit/ehr_go_live_planning_checklist.pdf
January 01, 2006 - Support escalation procedures (procedures that define what actions will be taken
in the event there is a problem … , who will manage the problem internally, and if
necessary, who will report the problem to the vendor
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digital.ahrq.gov/sites/default/files/docs/medicaid/health-it-implementation.pdf
December 01, 2005 - Advancing Excellence in Health Care
Technology: Security
Problem: Lack of trust in data security is … : Getting data out of the system is also a big problem in many
systems. … Advancing Excellence in Health Care
Technology: Applications
Problem: The user interface is a critical … Problem: “Alert Fatigue” is a big problem with EHR’s today
– Too many alerts, many of which may or may … – Same thing applies to when a diagnosis is made and a problem
documented.
-
psnet.ahrq.gov/node/33812/psn-pdf
August 01, 2016 - The problem is that, unlike hospitals, dental offices are not supervised until a
serious adverse event … A good example is the problem with disinfection and sterilization procedures. … BPP: We have a problem because we have developed anonymous reporting systems, but the judge can
ask … That's a problem we have not resolved. … Once you know the problem and how to
mitigate it, I think it's impossible to stop the process.
-
psnet.ahrq.gov/node/43091/psn-pdf
May 30, 2014 - professionalism in patient safety, and an
AHRQ WebM&M perspective reviewed strategies to identify and manage problem … https://psnet.ahrq.gov/web-mm/do-not-disturb
https://psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors
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www.uspreventiveservicestaskforce.org/uspstf/behavioral-counseling-interventions-an-evidence-based-approach---table-2
November 01, 2013 - influence behavioral choices
Health belief model
Peoples' perceptions of the threat of a health problem … and appraisal of behavior recommended to prevent or manage problem.
-
psnet.ahrq.gov/node/43904/psn-pdf
October 13, 2015 - Recent interventions, such as barcode medication administration systems, may help mitigate this
problem … While these findings suggest a possible robust
solution to this common problem, major limitations to
-
psnet.ahrq.gov/node/44542/psn-pdf
December 22, 2018 - Discordance between patient preferences for end-of-life care and documentation of their wishes is a
common problem … stop-silent-misdiagnosis-patients-preferences-matter
https://psnet.ahrq.gov/perspective/overuse-patient-safety-problem
-
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
-
psnet.ahrq.gov/node/49769/psn-pdf
September 01, 2016 - A Different Kind of System Problem
In our experience, most hospital-based practitioners admit that they … are aware of "problem" colleagues who
attract multiple complaints, underperform, behave poorly, or … doctors as another form of systems problem.(6) That is, some doctors will perform poorly, but it is … of multiple complaints), remediation
options should be chosen based on the nature of the underlying problem … Problem doctors: is there a system-level solution? Ann Intern Med.
2006;144:107-115.
-
psnet.ahrq.gov/node/42639/psn-pdf
November 08, 2013 - tolerated in health care despite the safety risks, this innovative program
demonstrates that this problem … disruptive-and-unprofessional-behavior
https://psnet.ahrq.gov/issue/patient-complaints-and-malpractice-risk
https://psnet.ahrq.gov/issue/problem-doctors-there-system-level-solution
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psnet.ahrq.gov/node/40024/psn-pdf
December 21, 2014 - This study
examined the problem of retained foreign bodies in pediatric surgery, using cases identified … Despite the persistence of this
problem, controversy remains around how to prevent such errors.
-
psnet.ahrq.gov/node/33825/psn-pdf
January 01, 2017 - Problem of many
hands
Many actors, both within and outside the health care organization, may be
implicated … The problem with root cause analysis. BMJ Qual
Saf. 2017;26:417-422. … Focusing more specifically on problems with RCA tools and techniques, Card described "the problem with … www.ncbi.nlm.nih.gov/pubmed/27340202
http://www.ncbi.nlm.nih.gov/pubmed/27340202
https://psnet.ahrq.gov/issue/problem … -5-whys
https://psnet.ahrq.gov/issue/problem-5-whys
https://psnet.ahrq.gov/issue/systems-approach-medicine-controversy-and-misconceptions
-
psnet.ahrq.gov/node/45113/psn-pdf
May 11, 2016 - controversial, the authors do highlight the lack of accurate
strategies for measuring safety events—a problem … avoidability-hospital-deaths-and-association-hospital-wide-mortality-ratios-retrospective
https://psnet.ahrq.gov/issue/problem-preventable-deaths
-
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.
-
digital.ahrq.gov/sites/default/files/docs/publication/BarrierstoMeaningfulUseAppendixA.pdf
January 01, 2010 - or older
have height, weight, and blood pressure recorded
as structured data
Maintain up-to-date problem … patients with an electronic
copy of their health information (including
diagnostic test results, problem … patients with timely electronic access to
their health information (including laboratory
results, problem
-
cds.ahrq.gov/sites/default/files/cds/artifact/476/Pain%20Management%20Summary%20Clincial%20Decision%20Support%20Toolkit_for%20Repository_0.xlsx
January 01, 2003 - is true:
Patient is >=18 and has one of these documented:
• Qualifying chronic pain diagnosis on problem … Management Summary CDS tool:
• Age >=65 and/or any one of the following:
These pull from the active problem … Test Patient Set-up
Patient 1
Problem List: contains qualifying chronic pain diagnosis (active) … Test Patient Set-up
Patient 1 Problem List: contains qualifying chronic pain diagnosis (active) and … Test Patient Set-up
Patient 1 age <18, with chronic pain on problem list
Patient 2 age<18, with