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Total Results: 7,452 records

Showing results for "problems".

361. The Soil, Not the Seed: The Real Problem with Root Cause Analysis | PSNet
     psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
     March 01, 2007 - unintended patient harm.( 2 ) Citing published studies going back as far as 2002, the authors reported problems … Similar problems have been reported by Maryland's Office of Health Care Quality (OHCQ), a state agency … Leaders must encourage RCA teams to delve deeper to find the system problems that contributed to the … System problems, often called latent conditions, cause an unhealthy environment that sets up failures … Next, the problems need to be fixed.

362. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39568/psn-pdf
     August 08, 2010 - Telephone management of acute and chronic conditions is common, but may be a source of errors and safety problems … telephone consultations were briefer and less detailed than face-to-face visits for similar clinical problems

363. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45098/psn-pdf
     May 04, 2016 - reducing-risk-and-promoting-patient-safety-nih-intramural-clinical-research- draft-report This publication outlines system problems … prioritization of research productivity over safety, insufficient processes for reporting and tracking problems

364. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46327/psn-pdf
     October 17, 2017 - Identifying patient and practice characteristics associated with patient-reported experiences of safety problems … Identifying patient and practice characteristics associated with patient-reported experiences of safety problems

365. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45617/psn-pdf
     November 30, 2016 - theory can be applied to diagnostic decision-making, this commentary presents a case that illustrates problems … etiology-diagnostic-errors-controlled-trial-system-1-versus-system-2-reasoning https://psnet.ahrq.gov/issue/clinician-identified-problems-and-solutions-delayed-diagnosis-primary-care-prioritize-study

366. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39975/psn-pdf
     March 03, 2011 - of surgical procedures to assess the incidence, types, and consequences of surgical communication problems … , and found that failure to discuss equipment problems and progress of the procedure were common, resulting

367. Effect of an in-hospital multifaceted clinical pharmacist intervention on the risk of readmission: a randomized clinical trial. | PSNet
     psnet.ahrq.gov/issue/effect-hospital-multifaceted-clinical-pharmacist-intervention-risk-readmission-randomized
     September 13, 2023 - Tool (MOAT): a prognostic model to target hospital pharmacists' input to prevent medication-related problems … July 20, 2016 Drug related problems and pharmacist interventions in a geriatric unit … February 15, 2011 Drug-related problems in medical wards with a computerized physician

368. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33571/psn-pdf
     March 15, 2025 - ubiquitous in hospitals and are a mainstay of efforts to detect patient safety events and quality problems … Safety Hazards provides a detailed discussion of other methods of identifying errors and latent safety problems … concerns that are worthy of attention, they do not provide insights into the epidemiology of safety problems … reports therefore provide a snapshot of safety issues, but on their own, cannot place the reported problems

369. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33638/psn-pdf
     August 01, 2006 - A few seminal publications helped to expose human error in anesthesia and its underlying causes as problems … Despite Jeep's leadership, the publication of data pointing to major problems in anesthesia safety and … value to safety concerns and paying greater attention to minor events that are harbingers of bigger problems … factors: the availability of data (both qualitative and quantitative) that identified many of the problems … We have many of the same problems we had a generation ago, and we've added some new ones: making changes

370. Urine a Tough Position | PSNet
     psnet.ahrq.gov/web-mm/urine-tough-position
     January 01, 2009 - A total of 180 laboratory problems were detected, for a crude frequency of 1.1 laboratory problems per … Of 180 reported problems, 49 impacted patient care (27%). … problems were the most common overall (33.9%), similar to the urine mishandling case presented here. … Classifying laboratory incident reports to identify problems that jeopardize patient safety. … Problems in laboratory testing in primary care. JAMA. 1996;275:635-9.[ go to PubMed ] 10.

371. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33812/psn-pdf
     August 01, 2016 - Bernardo Perea-Pérez: There are several potentially significant problems in dentistry. … First, there are problems with the methods of disinfection and sterilization of dental instruments, … Maybe the fourth concern is problems related to drug interactions, especially in elderly people. … On the other hand, the main problems are dangers to the privacy of health data and the possibility that … The patient safety field in general has focused on systems that have problems rather than individual

372. Reduced verification of medication alerts increases prescribing errors. | PSNet
     psnet.ahrq.gov/issue/reduced-verification-medication-alerts-increases-prescribing-errors
     January 09, 2019 - February 14, 2024 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

373. In Conversation With…Kaveh G. Shojania, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
     September 01, 2011 - You're supposed to try to identify teamwork, communication, or patient identification problems and use … 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. … KS : There are two problems there, you're right.

374. 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.

375. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/846935/psn-pdf
     March 29, 2023 - is screening, which can help identify individuals who may be at risk for developing mental health problems … Healthcare providers should routinely screen for perinatal mental health problems, including depression … Patients with perinatal mental health problems require ongoing follow-up care to ensure that they are … Individuals should receive education on the signs and symptoms of perinatal mental health problems, … as well as the potential risks associated with untreated mental health problems during pregnancy and

376. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36549/psn-pdf
     March 21, 2017 - defined "error" more broadly than traditional definitions, including such issues as falls, communication problems … least one error-related concern during their hospitalization, most commonly due to well-recognized problems

377. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39173/psn-pdf
     November 02, 2014 - patient safety over the past decade, most health care organizations still experience persistent safety problems … These include transparency in disclosing errors and quality problems, integration of care across teams

378. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39236/psn-pdf
     May 25, 2010 - Do emergency physicians attribute drug-related emergency department visits to medication-related problems … Do emergency physicians attribute drug-related emergency department visits to medication-related problems

379. Biomedical Complexity and Error. | PSNet
     psnet.ahrq.gov/issue/biomedical-complexity-and-error
     August 21, 2019 - February 17, 2019 Classifying laboratory incident reports to identify problems that jeopardize … September 7, 2005 Unintended Consequences: New Problems and New Solutions.

380. In Conversation with... Charles Ornstein | PSNet
     psnet.ahrq.gov/perspective/conversation-charles-ornstein
     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.