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Total Results: 1,785 records

Showing results for "problems".

81. A Pill Organizing Plight | PSNet
    psnet.ahrq.gov/web-mm/pill-organizing-plight
    June 19, 2018 - medicine resident visited one of his patients—an 80-year-old, Spanish-speaking woman with multiple medical problems … As a result of these problems, on some days the patient was taking up to five blood pressure pills when … adjustment in patients with renal dysfunction, and the use of antipsychotics for patients with behavioral problems … Additionally, pharmacist-led brown bag medication reviews can identify significant drug-related problems … bedside counseling, and a follow-up phone call within 48 hours to identify and resolve medication-related problems

82. In Conversation With… Erik Hollnagel, PhD | PSNet
    psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd
    February 26, 2025 - Erik Hollnagel : I've worked with safety-related problems in a wide variety of industries since the late … Everybody tends to look at what they do themselves and see all the problems, and they look at what others … What characterizes the problems in health care is that the professionals who work there are under so … They sell standardized systems that don't really fit the particular hospital, and it creates problems … The problems are not easily solved because the problems are not of our making; the problems are in the

83. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33582/psn-pdf
    September 15, 2024 - The field of human factors engineering attempts to identify and address safety problems that arise due … Establishing a culture of safety entails obtaining information on perceived safety problems from staff … attuned to the cultural aspects of how care is provided, can determine distinct classes of safety problems … RCA is a formal multidisciplinary process that has the explicit goal of identifying systematic problems … seeking to engage patients in safety efforts, and some studies have shown that patients can identify problems

84. Computerized Provider Order Entry | PSNet
    psnet.ahrq.gov/primer/computerized-provider-order-entry
    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 … Entry Systems More or new work for clinicians Unfavorable workflow issues Never-ending system demands Problems

85. ISMP medication error report analysis. | PSNet
    psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-7
    June 16, 2019 - This monthly selection of medication error reports provides examples of problems related to poorly scanned

86. The spectrum of hospitalization-associated harm in the elderly. | PSNet
    psnet.ahrq.gov/issue/spectrum-hospitalization-associated-harm-elderly
    April 06, 2022 - Early readmissions to the department of medicine as a screening tool for monitoring quality of care problems … September 7, 2022 Problems with health information technology and their effects on care … January 10, 2024 Medicines related problems (MRPs) originating in primary care settings

87. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33589/psn-pdf
    September 15, 2024 - Thus, high reliability organizations work to create an environment in which potential problems are anticipated … all personnel actively think about what could go wrong and are alert to small signs of potential problems … organizational climate is such that all staff members are comfortable speaking up about potential safety problems … monitoring so they may identify potential safety threats quickly and either respond before safety problems

88. ISMP medication error report analysis. | PSNet
    psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-9
    June 16, 2019 - report discussed medication reconciliation  and community pharmacists, look-alike and sound-alike problems

89. ISMP medication error report analysis. | PSNet
    psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-15
    June 16, 2019 - name confusion, an unsafe process for outdated drug replacement, and smart pump dose administration problems

90. ISMP medication error report analysis. | PSNet
    psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-2
    June 16, 2019 - This monthly selection of medication error reports provides examples of problems with neuromuscular blocking

91. ISMP medication error report analysis. | PSNet
    psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-12
    June 16, 2019 - This monthly selection of medication error reports provides examples of problems related to medication

92. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33601/psn-pdf
    December 15, 2024 - 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.

93. A systematic review of the psychological literature on interruption and its patient safety implications. | PSNet
    psnet.ahrq.gov/issue/systematic-review-psychological-literature-interruption-and-its-patient-safety-implications
    September 24, 2016 - 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 … in Acute Hospital Care Units April 26, 2023 Mind the overlap: how system problems

94. Safer prescribing and care for the elderly (SPACE): cluster randomised controlled trial in general practice. | PSNet
    psnet.ahrq.gov/issue/safer-prescribing-and-care-elderly-space-cluster-randomised-controlled-trial-general-practice
    November 18, 2020 - November 18, 2020 The frequency and nature of prescribing problems by general practitioners … January 4, 2012 New problems and iatrogenic events among older adults in the first 30 … April 8, 2020 Non-dispensing pharmacists' actions and solutions of drug therapy problems

95. The effect of cognitive load and task complexity on automation bias in electronic prescribing. | PSNet
    psnet.ahrq.gov/issue/effect-cognitive-load-and-task-complexity-automation-bias-electronic-prescribing
    May 01, 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

96. 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

97. Complaints to the Parliamentary and Health Service Ombudsman. | PSNet
    psnet.ahrq.gov/issue/complaints-about-acute-trusts-2016-2017
    April 17, 2024 - trusts to track complaints received and responded to, identify common themes, and uncover recurring problems

98. Clinical safety of England's national programme for IT: a retrospective analysis of all reported safety events 2005 to 2011. | PSNet
    psnet.ahrq.gov/issue/clinical-safety-englands-national-programme-it-retrospective-analysis-all-reported-safety
    December 31, 2014 - Using FDA reports to inform a classification for health information technology safety problems … December 31, 2014 Identifying patient safety problems associated with information technology … February 14, 2024 Using automated methods to detect safety problems with health information … May 26, 2021 Identifying patient safety problems associated with information technology

99. 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

100. In Conversation with...Patrick S. Romano, MD, MPH | PSNet
     psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph
     July 10, 2024 - Everyone who has looked at multiple data sources has found that, in any one data source, you see problems … With systems based on ICD-9-CM codes, like the Patient Safety Indicators, there are problems with how … With systems based on triggers, there are problems with the inherent performance of those triggers and … How do you know where your problems are? How do you know what you need to improve? … are, what the root causes are, why failures are occurring, and how to fix those problems.