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Showing results for "problems".

61. Towards a framework for managing risk associated with technology-induced error. | PSNet
    psnet.ahrq.gov/issue/towards-framework-managing-risk-associated-technology-induced-error
    May 10, 2013 - This commentary discusses an enterprise risk management framework to assess and address problems associated … 10, 2013 Technology induced error and usability: the relationship between usability problems

62. Factors associated with barcode medication administration technology that contribute to patient safety: an integrative review. | PSNet
    psnet.ahrq.gov/issue/factors-associated-barcode-medication-administration-technology-contribute-patient-safety
    September 28, 2010 - If nurses experience problems while using barcode medication technologies , this can result in patient … May 17, 2023 Impact of patient communication problems on the risk of preventable adverse

63. Adverse Health Events in Minnesota: Annual Reports. | PSNet
    psnet.ahrq.gov/issue/adverse-health-events-minnesota-15th-annual-public-report
    February 28, 2015 - The National Quality Forum has defined 29 never events —patient safety problems that should never … January 8, 2020 Identifying patient safety problems associated with information technology

64. Managing the Unexpected: Sustained Performance in a Complex World, Third Edition. | PSNet
    psnet.ahrq.gov/issue/managing-unexpected-sustained-performance-complex-world-3rd-edition
    November 04, 2015 - Sutcliffe, high-reliability organizations operate under challenging conditions yet experience fewer problems … May 8, 2013 First, Do Less Harm: Confronting the Inconvenient Problems of Patient Safety

65. Targeted chart review of pediatric patient safety events identified by the Agency for Healthcare Research and Quality's Patient Safety Indicators methodology. | PSNet
    psnet.ahrq.gov/issue/targeted-chart-review-pediatric-patient-safety-events-identified-agency-healthcare-research
    April 11, 2011 - are screening tools that can be applied to administrative data to identify potential patient safety problems … review, certain specific PSIs (such as failure to rescue ) did not accurately identify patient safety problems

66. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. | PSNet
    psnet.ahrq.gov/issue/deficits-communication-and-information-transfer-between-hospital-based-and-primary-care
    January 25, 2017 - suboptimal communication between hospital physicians and outpatient physicians could contribute to these problems … This study systematically reviewed the literature to determine the frequency of communication problems

67. Patient-reported safety and quality of care in outpatient oncology. | PSNet
    psnet.ahrq.gov/issue/patient-reported-safety-and-quality-care-outpatient-oncology
    January 23, 2012 - reviewed by physicians, who classified reported adverse events as adverse events , near misses , or problems … Managers Quality and Safety Professionals Medical Oncology Discontinuities, Gaps, and Hand-Off Problems

68. Work-arounds observed by fourth-year nursing students. | PSNet
    psnet.ahrq.gov/issue/work-arounds-observed-fourth-year-nursing-students
    July 30, 2014 - These results are consistent with prior studies linking nurse understaffing to patient safety problems … September 27, 2023 Drug-related problems and polypharmacy in nursing home residents:

69. Patients' concerns about medical errors during hospitalization. | PSNet
    psnet.ahrq.gov/issue/patients-concerns-about-medical-errors-during-hospitalization
    December 22, 2008 - 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

70. The care transitions intervention: results of a randomized controlled trial. | PSNet
    psnet.ahrq.gov/issue/care-transitions-intervention-results-randomized-controlled-trial
    July 10, 2008 - Prior studies  have documented the safety problems that befall patients with complex illnesses at the … Providers Health Care Executives and Administrators Patients Discontinuities, Gaps, and Hand-Off Problems

71. Language proficiency and adverse events in US hospitals: a pilot study. | PSNet
    psnet.ahrq.gov/issue/language-proficiency-and-adverse-events-us-hospitals-pilot-study
    January 23, 2012 - Events in patients with LEP were frequently attributable to communication problems and were more likely … Hospitals Physicians Health Care Executives and Administrators Discontinuities, Gaps, and Hand-Off Problems

72. 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.

73. 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.

74. Deriving ICD-10 codes for patient safety indicators for large-scale surveillance using administrative hospital data. | PSNet
    psnet.ahrq.gov/issue/deriving-icd-10-codes-patient-safety-indicators-large-scale-surveillance-using-administrative
    December 29, 2014 - AHRQ Patient Safety Indicators (PSIs) have been utilized to identify safety problems and suboptimal … Application of these novel PSIs in over 10 years of hospital discharge data uncovered safety problems

75. The PRONE score: an algorithm for predicting doctors' risks of formal patient complaints using routinely collected administrative data. | PSNet
    psnet.ahrq.gov/issue/prone-score-algorithm-predicting-doctors-risks-formal-patient-complaints-using-routinely
    September 07, 2011 - Past studies have found a correlation between patient complaints and patient safety problems. … October 17, 2018 Identifying patient safety problems associated with information technology

76. Incorrect surgical procedures within and outside of the operating room. | PSNet
    psnet.ahrq.gov/issue/incorrect-surgical-procedures-within-and-outside-operating-room
    November 21, 2011 - considered never events , as they are devastating errors that arise from serious underlying safety problems … Root cause analysis was used to identify underlying safety problems.

77. The cognitive health system. | PSNet
    psnet.ahrq.gov/issue/cognitive-health-system
    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

78. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33564/psn-pdf
    March 15, 2025 - Examples of these advantages include: averting problems with handwriting, similar drug names, drug interactions … In that study, although overall prescribing errors decreased, problems related to the CPOE system itself … In many cases, these workarounds represent reasonable adaptations due to problems with the design and … Food and Drug Administration white paper (summarized here), current CPOE systems have fundamental problems … Systems More or new work for clinicians Unfavorable workflow issues Never-ending system demands Problems

79. The impact of automated notification on follow-up of actionable tests pending at discharge: a cluster-randomized controlled trial. | PSNet
    psnet.ahrq.gov/issue/impact-automated-notification-follow-actionable-tests-pending-discharge-cluster-randomized
    March 04, 2015 - Previous WebM&M commentaries explored problems related to tests pending at discharge and how organizations … Information Professionals Pathology and Laboratory Medicine Discontinuities, Gaps, and Hand-Off Problems

80. The problem with medication reconciliation. | PSNet
    psnet.ahrq.gov/issue/problem-medication-reconciliation
    May 08, 2017 - Commentary The problem with medication reconciliation. Citation Text: Pevnick JM, Shane R, Schnipper JL. The problem with medication reconciliation. BMJ Qual Saf. 2016;25(9):726-730. doi:10.1136/bmjqs-2015-004734. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNo…