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Total Results: 1,785 records

Showing results for "problems".

101. Maternity ward at Highland under fire from patients. | PSNet
     psnet.ahrq.gov/issue/maternity-ward-highland-under-fire-patients
     December 12, 2018 - This article describes a variety of quality and safety problems in the labor and delivery ward at a large

102. TeamSTEPPS Video Toolkit. | PSNet
     psnet.ahrq.gov/issue/teamstepps-video-toolkit
     April 06, 2022 - Problems in communication are common contributors to patient care mistakes.

103. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please | PSNet
     psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
     September 01, 2011 - the incident to get a handle on some problems in your institution. … The plausible part of this hope is that some institutions would have idiosyncratic problems, which is … to say problems other than those highlighted in the literature. … Many such reports, for instance ones involving opiates or anticoagulants, capture problems that occur … KS : There are two problems there, you're right.

104. Misleading Complaint | PSNet
     psnet.ahrq.gov/web-mm/misleading-complaint
     December 01, 2009 - man with a history of alcoholism presented to the emergency department (ED) with complaints of knee problems … checklist designed to aid and offload clinicians' intuition and memory when solving complex clinical problems … Diagnostic tools do move the physician's cognitive challenges upstream to detect, identify, and frame problems

105. 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 - But what really captured my interest were the problems at a hospital in South Los Angeles, King/Drew … So those two things together made us open our eyes to what could be serious problems at King. … Even the best hospitals in the country have problems, and there are problems that they can fix. … I understood about safety problems. I understood about system problems. … and the role that people play in problems, and the interplay between the two.

106. Speaking up and taking action: psychological safety and joint problem-solving orientation in safety improvement. | PSNet
     psnet.ahrq.gov/issue/speaking-and-taking-action-psychological-safety-and-joint-problem-solving-orientation-safety
     October 21, 2020 - the association of psychological safety and joint-problem-solving orientation (JPS; e.g., addressing problems

107. Dental Patient Safety Foundation. | PSNet
     psnet.ahrq.gov/issue/dental-patient-safety-foundation
     October 28, 2020 - organization collects, analyzes , and shares insights drawn from reports of errors, near misses, and systems problems

108. Supporting second victims. | PSNet
     psnet.ahrq.gov/issue/supporting-second-victims
     February 15, 2023 - This newsletter article describes problems second victims may experience and outlines how organizations

109. NHS staff cried in safety interviews, says watchdog. | PSNet
     psnet.ahrq.gov/issue/nhs-staff-cried-safety-interviews-says-watchdog
     August 30, 2023 - Clinicians interviewed revealed serious problems with the work cultures.

110. Electronic Health Records | PSNet
     psnet.ahrq.gov/primer/electronic-health-records
     March 15, 2025 - However, the investigators found several problems as well. … The latter problems resulted in interruptions and distraction, which can contribute to medical error. … lack of clarity in sources and date of information presented,  alert fatigue , and other usability problems … A review of studies of EHR issues that present patient safety risks found numerous problems with software … Problems With Software Functionality and Usability.

111. Safer Clinical Systems: Evaluation Findings. | PSNet
     psnet.ahrq.gov/issue/safer-clinical-systems-evaluation-findings
     March 03, 2025 - processes and improvement work in health care organizations in order to address underlying system problems

112. Hospitals Can Take Key Steps to Improve Safe Use of Digital Systems. | PSNet
     psnet.ahrq.gov/issue/hospitals-can-take-key-steps-improve-safe-use-digital-systems
     April 01, 2020 - Tracking problems with health information technology (Health IT) is an important strategy to drive improvement

113. Improving Patient Care Through Safe Health IT. | PSNet
     psnet.ahrq.gov/issue/improving-patient-care-through-safe-health-it
     August 12, 2020 - This report introduces problems that surface due to poor design of health IT systems, summarizes expert

114. The Role of Patient-facing Technologies to Empower Patients and Improve Safety | PSNet
     psnet.ahrq.gov/perspective/role-patient-facing-technologies-empower-patients-and-improve-safety
     November 01, 2017 - So in some of our work, caregivers have designed different kinds of apps to address those problems. … RW : You've talked about patients seeing things in their record and identifying problems. … So in some ways, I see this as more likely to mitigate safety problems and concerns than cause problems … How do you see that and do you see any solutions to those problems? WP : That's a big problem. … One solution could be some triaging of who deals with what kinds of problems.

115. Patient Safety Authority. | PSNet
     psnet.ahrq.gov/issue/patient-safety-authority
     October 07, 2020 - independent state agency charged with taking steps to reduce and eliminate medical errors by identifying problems

116. Dying for Care. | PSNet
     psnet.ahrq.gov/issue/dying-care
     January 18, 2023 - collection of resources examines data and documentation involving one nursing home chain to reveal systemic problems

117. How the pandemic defeated America. | PSNet
     psnet.ahrq.gov/issue/how-pandemic-defeated-america
     July 01, 2020 - The piece highlights systemic problems such as lack of transparency , investment in public health and

118. Unintended Consequences of CPOE | PSNet
     psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
     September 01, 2004 - In a study of medication errors facilitated by CPOE, researchers identified 18 fundamental problems in … CPOE systems.( 5 ) Subsequently, usability experts traced 12 of the 18 problems to usability design … These poor interfaces transform old problems into new ones; they eliminate the problem of illegible or … .( 15 ) Such monitoring might have identified this and related problems prior to their being discovered … Ironies of automation: increasing levels of automation can increase, rather than decrease, the problems

119. Risks to Medication Delivery Using Ambulatory Infusion Pumps – Design and Usability in Inpatient Settings. | PSNet
     psnet.ahrq.gov/issue/risks-medication-delivery-using-ambulatory-infusion-pumps-design-and-usability-inpatient
     November 29, 2023 - , pump maintenance, and medication administration resulted in patient harm when medication delivery problems

120. Development of "SWARM" as a model for high reliability, rapid problem solving, and institutional learning. | PSNet
     psnet.ahrq.gov/issue/development-swarm-model-high-reliability-rapid-problem-solving-and-institutional-learning
     November 16, 2022 - discusses the development and implementation of the SWARM tool—a unit-based mechanism to rapidly analyze problems