Results

Total Results: 7,452 records

Showing results for "problems".

241. Measuring and Responding to Deaths From Medical Errors | PSNet
     psnet.ahrq.gov/perspective/measuring-and-responding-deaths-medical-errors
     April 01, 2008 - researchers and commentators have produced widely varying estimates of the death toll ascribable to safety problems … conduct standardized reviews of deaths in order to identify individual clinician issues or systematic problems … within a single organization, and reviewing deaths may provide only a limited view of patient safety problems … they tend to identify a limited subset of issues, such as diagnostic errors, failure to rescue , or problems … formal strategies for identifying preventable deaths and analyzing these deaths to determine systematic problems

242. Rethinking Root Cause Analysis | PSNet
     psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
     August 21, 2016 - In a widely cited 2016 commentary, Peerally and colleagues described eight problems with RCA as currently … Problems With Root Cause Analysis in Health Care 1. … Focusing more specifically on problems with RCA tools and techniques, Card described " the problem with … Improving the RCA Process In response to these problems with the RCA process, the National Patient … The literature published in 2016 highlights ongoing problems with RCA in health care, most importantly

243. Medication errors in an intensive care unit. | PSNet
     psnet.ahrq.gov/issue/medication-errors-intensive-care-unit
     October 12, 2022 - Pharmacy problems, including lack of medication availability and transcription problems, were the principal

244. Diagnostic error in internal medicine. | PSNet
     psnet.ahrq.gov/issue/diagnostic-error-internal-medicine
     May 25, 2022 - These include system-related problems such as inefficient processes and cognitive problems such as failure

245. Reducing Risk and Promoting Patient Safety for NIH Intramural Clinical Research—Final Report. | PSNet
     psnet.ahrq.gov/issue/reducing-risk-and-promoting-patient-safety-nih-intramural-clinical-research-draft-report
     November 18, 2020 - This publication outlines system problems at a large research institution that could compromise patient … prioritization of research productivity over safety, insufficient processes for reporting and tracking problems

246. An innovative collaborative model of care for undiagnosed complex medical conditions. | PSNet
     psnet.ahrq.gov/issue/innovative-collaborative-model-care-undiagnosed-complex-medical-conditions
     November 21, 2021 - Lack of collaboration among the clinical team can contribute to diagnostic problems . … Health Care Providers Pediatrics Diagnostic Errors Discontinuities, Gaps, and Hand-Off Problems

247. Towards a unified model of accident causation: refining and validating the systems thinking safety tenets. | PSNet
     psnet.ahrq.gov/issue/towards-unified-model-accident-causation-refining-and-validating-systems-thinking-safety
     March 14, 2022 - organizations to encourage learning from failures and identifying solutions to complex patient safety problems … Patient race and opioid misuse history influence provider risk perceptions for future opioid-related problems

248. Improving patient safety: avoiding unread imaging exams in the National VA enterprise electronic health record. | PSNet
     psnet.ahrq.gov/issue/improving-patient-safety-avoiding-unread-imaging-exams-national-va-enterprise-electronic
     March 12, 2025 - The study team identified several technical and process problems that contributed to these unread studies … February 1, 2023 Problems in care and avoidability of death after discharge from intensive

249. I-PASS checklist: a powerful tool for patient handoffs. | PSNet
     psnet.ahrq.gov/issue/i-pass-checklist-powerful-tool-patient-handoffs
     November 21, 2018 - Structured handoffs can reduce communication problems that contribute to medical error. … Topic Outpatient Pharmacy Pharmacists Pharmacy Discontinuities, Gaps, and Hand-Off Problems

250. More than algorithms: an analysis of safety events involving ML-enabled medical devices reported to the FDA. | PSNet
     psnet.ahrq.gov/issue/more-algorithms-analysis-safety-events-involving-ml-enabled-medical-devices-reported-fda
     May 01, 2019 - January 9, 2019 Using automated methods to detect safety problems with health information … February 14, 2024 Problems with health information technology and their effects on care … April 24, 2018 Identifying patient safety problems associated with information technology … August 11, 2021 Insulin pumps have most reported problems in FDA database.

251. Errors associated with oxytocin use: a multi-organization analysis by ISMP and ISMP Canada. | PSNet
     psnet.ahrq.gov/issue/errors-associated-oxytocin-use-multi-organization-analysis-ismp-and-ismp-canada
     February 23, 2022 - include prescribing, look alike/sound alike packaging, preparation, administration and communication problems … Updated guidance needed for longstanding large volume parenteral (LVP) labeling and packaging problems

252. Smart infusion pump investigations after an unexplained over-infusion. | PSNet
     psnet.ahrq.gov/issue/smart-infusion-pump-investigations-after-unexplained-over-infusion
     May 03, 2023 - This article discusses infusion problems unrelated to user error that went undetected by the technology … November 10, 2021 Insulin pumps have most reported problems in FDA database.

253. Child-specific risk factors and patient safety. | PSNet
     psnet.ahrq.gov/issue/child-specific-risk-factors-and-patient-safety
     February 02, 2022 - These factors contributed to nearly half of the identified patient safety problems. … elderly or in children, present an opportunity to design tailored interventions to reduce patient safety problems

254. The science of interruption. | PSNet
     psnet.ahrq.gov/issue/science-interruption
     September 04, 2024 - December 6, 2023 Using automated methods to detect safety problems with health information … February 8, 2023 Problems with health information technology and their effects on care … April 24, 2018 Identifying patient safety problems associated with information technology

255. Testing and Labeling Medical Devices for Safety in the Magnetic Resonance (MR) Environment. | PSNet
     psnet.ahrq.gov/issue/testing-and-labeling-medical-devices-safety-magnetic-resonance-mr-environment
     March 12, 2019 - appropriately to support their safe use in the MRI environment and encourages organizational reporting of problems … June 6, 2018 Safety Problems With Your Child's Medical Device?

256. Determinants of patient-reported medication errors: a comparison among seven countries. | PSNet
     psnet.ahrq.gov/issue/determinants-patient-reported-medication-errors-comparison-among-seven-countries
     July 29, 2020 - errors in the ambulatory setting , and patients consistently voice concern about care coordination problems … Part 1: a review of the extent and causes of medication problems 2002-2008.

257. Consequences of running more operating theatres than anaesthetists to staff them: a stochastic simulation study. | PSNet
     psnet.ahrq.gov/issue/consequences-running-more-operating-theatres-anaesthetists-staff-them-stochastic-simulation
     October 19, 2022 - estimate the risk of adverse events due to unavailability of an anesthesiologist to attend to urgent problems … Operating Room Physicians Anesthesiology Surgery Discontinuities, Gaps, and Hand-Off Problems

258. In Conversation With… Mark Chassin, MD, MPP, MPH | PSNet
     psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph
     April 26, 2023 - Mark Chassin : Back when I was on the hospital side struggling with quality and safety problems, it always … They find these unsafe conditions when the problems are very small—way upstream from posing serious risk … but there was no serious effort to solve the problems. … You empower employees to identify problems that you then focus on and solve, and they see that their … Solving those problems with Lean, improving the outcomes of processes with Six Sigma, and then wrapping

259. Could Efforts to Fight the Coronavirus Lead to Overuse of Antibiotics? | PSNet
     psnet.ahrq.gov/issue/could-efforts-fight-coronavirus-lead-overuse-antibiotics
     May 11, 2011 - This report discusses problems associated with antibiotic prescribing during the first 6 months of the … Systemic problems arising from the situation include disparities associated with antibiotic administration

260. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41405/psn-pdf
     December 30, 2014 - Failure to address both operational and cultural factors in cardiac surgery has led to serious safety problems … Many types of hazards were identified, including problems with communication and teamwork, poor interoperability … The authors make detailed recommendations to guide institutions in addressing these problems.