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Total Results: 1,785 records

Showing results for "problems".

201. Applying Lean Sigma solutions to mistake-proof the chemotherapy preparation process. | PSNet
     psnet.ahrq.gov/issue/applying-lean-sigma-solutions-mistake-proof-chemotherapy-preparation-process
     September 02, 2015 - This article describes how one hospital used failure mode and effect analysis  to identify problems

202. The Report of the Morecambe Bay Investigation. | PSNet
     psnet.ahrq.gov/issue/report-morecambe-bay-investigation
     November 16, 2005 - delivered in the maternity unit of a National Health Service Trust between 2004 and 2013 which uncovered problems

203. Discharge Fumbles | PSNet
     psnet.ahrq.gov/web-mm/discharge-fumbles
     September 09, 2009 - Patient safety problems, similar to the two illustrative cases, are exceedingly common in the early discharge … They must be empowered to recognize and speak up about the development of important new health problems … Conclusion Safety problems frequently do occur at discharge. … Despite a preliminary understanding of what causes those problems, more research is needed to better … elucidate both the problems and potential solutions.

204. Readmissions and Adverse Events After Discharge | PSNet
     psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge
     April 27, 2022 - Systematic problems in care transitions are at the root of most adverse events that arise after discharge … families) must understand their diagnosis, their follow-up needs, and whom to contact with questions or problems … View More See More About The Topic Discontinuities, Gaps, and Hand-Off Problems

205. A biased test kept thousands of Black people from getting a kidney transplant. | PSNet
     psnet.ahrq.gov/issue/biased-test-kept-thousands-black-people-getting-kidney-transplant
     September 02, 2016 - facility leaves 10 hospitalized December 4, 2019 Insulin pumps have most reported problems … Related Resources Top Penn State Health surgeon warned leaders about transplant problems

206. Understanding models of error and how they apply in clinical practice. | PSNet
     psnet.ahrq.gov/issue/understanding-models-error-and-how-they-apply-clinical-practice
     October 11, 2016 - June 27, 2016 Analysis of pharmacist-identified medication-related problems at two United … Tool (MOAT): a prognostic model to target hospital pharmacists' input to prevent medication-related problems

207. People, processes, health IT and accurate patient identification. | PSNet
     psnet.ahrq.gov/issue/people-processes-health-it-and-accurate-patient-identification
     April 11, 2018 - This newsletter article reviews common problems related to patient identification and recommends strategies

208. Medicare says it won't cover hospital errors. | PSNet
     psnet.ahrq.gov/issue/medicare-says-it-wont-cover-hospital-errors
     November 28, 2016 - hospitals and the increased efforts it is likely to create for hospitals to document certain patient problems

209. Developing a framework for nursing handover in the emergency department: an individualised and systematic approach. | PSNet
     psnet.ahrq.gov/issue/developing-framework-nursing-handover-emergency-department-individualised-and-systematic
     October 06, 2016 - Participating nurses believed that the essential data included demographics, presenting problems, nursing

210. Academic year-end transfers of outpatients from outgoing to incoming residents: an unaddressed patient safety issue. | PSNet
     psnet.ahrq.gov/issue/academic-year-end-transfers-outpatients-outgoing-incoming-residents-unaddressed-patient
     January 27, 2016 - This commentary discusses the problems inherent when patient care responsibilities are transferred from

211. Identified safety risks with splitting and crushing oral medications. | PSNet
     psnet.ahrq.gov/issue/identified-safety-risks-splitting-and-crushing-oral-medications
     September 24, 2010 - explains the risks associated with crushing or splitting medications and offers suggestions to prevent problems

212. Application of AHRQ patient safety indicators to English hospital data. | PSNet
     psnet.ahrq.gov/issue/application-ahrq-patient-safety-indicators-english-hospital-data
     September 20, 2011 - Quality's Patient Safety Indicators were found to have limited utility in screening for patient safety problems

213. The interrelationship of isolation precautions and adverse events in an acute care facility. | PSNet
     psnet.ahrq.gov/issue/interrelationship-isolation-precautions-and-adverse-events-acute-care-facility
     September 24, 2010 - corroborating prior research showing that these patients are at elevated risk for patient safety problems

214. Using a multi-method, user centred, prospective hazard analysis to assess care quality and patient safety in a care pathway. | PSNet
     psnet.ahrq.gov/issue/using-multi-method-user-centred-prospective-hazard-analysis-assess-care-quality-and-patient
     May 27, 2011 - The authors describe a method for identifying potential quality and safety problems in a care pathway

215. Driving improvement in patient care: lessons from Toyota. | PSNet
     psnet.ahrq.gov/issue/driving-improvement-patient-care-lessons-toyota
     September 24, 2016 - Individuals are expected to identify barriers and problems in the workplace and then are given the responsibility

216. Evaluation of symptom checkers for self diagnosis and triage: audit study. | PSNet
     psnet.ahrq.gov/issue/evaluation-symptom-checkers-self-diagnosis-and-triage-audit-study
     December 08, 2021 - Tool (MOAT): a prognostic model to target hospital pharmacists' input to prevent medication-related problems … Patient safety culture, health information technology implementation, and medical office problems

217. We want to know: eliciting hospitalized patients' perspectives on breakdowns in care. | PSNet
     psnet.ahrq.gov/issue/we-want-know-eliciting-hospitalized-patients-perspectives-breakdowns-care
     January 12, 2022 - Related Resources From the Same Author(s) Encouraging patients to speak up about problems … Identifying patient and practice characteristics associated with patient-reported experiences of safety problems

218. Where Does Risk-Adjusted Mortality Fit Into a Safety Measurement Program? | PSNet
     psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
     March 01, 2015 - They can falsely label hospitals as poor performers and fail to detect many others that harbor problems … Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review … The regulators also received complaints from patients that also drew attention to the problems at Mid … They had some problems with young men having organ failure in a drug trial, and they'd had some excess … In his report he said that all 14 hospitals had problems.

219. Learning Not Blaming. | PSNet
     psnet.ahrq.gov/issue/learning-not-blaming
     March 28, 2018 - The National Health Service (NHS) has a history of sharing analyses of problems in its system.

220. Medication-related Malpractice Risks. 2016 CRICO Strategies National CBS Report. | PSNet
     psnet.ahrq.gov/issue/medication-related-malpractice-risks-2016-crico-strategies-national-cbs-report
     July 18, 2018 - medication-related malpractice claims found that 1 in 9 malpractice cases were associated with medication problems