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www.ahrq.gov/patient-safety/settings/hospital/resource/nicu/packet/apa2.html
December 01, 2013 - Return to Appendix Contents
Managing Breathing Problems
How Can I Manage My Child's Breathing Problems … Damaged lung tissue causes breathing and health problems. … Problems breathing.
Fast breathing.
Not eating well.
How is RSV Spread?
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Drews_15.pdf
February 26, 2008 - Consequently, errors were seen as an exception in a system that otherwise performed
well; no other problems … In
addition, critical care patients often have lower physiologic reserves to help them cope with
problems … Reason’s model of error (modified after Dean et al)14
4
Devices
Potential problems with monitoring … The problem is that comprehensive studies of medical device problems
are lacking.15 That alarms are … Given the
problems outlined above, it is no surprise to find that under time pressure, the operation
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www.ahrq.gov/sites/default/files/2024-07/nuckols-report.pdf
January 01, 2024 - intervention,
computerized physician order entry.
4
Scope
Researchers have extensively documented problems … gross domestic product.(7) Other problems also limit length and quality of life. … The existence of
competing problems requires policymakers to prioritize—whether explicitly or implicitly—quality … quantified the value of patient
safety interventions.(11) Researchers often describe patient safety problems … Reasons can include budgetary constraints, a tendency to focus on
short-term problems, and political
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www.ahrq.gov/sites/default/files/2024-07/earp-report.pdf
January 01, 2024 - Institute of Medicine in 1999 and 2001 helped establish
the need for this approach by identifying the twin problems … Together, they
served to identify the twin problems of medical error and poor-quality healthcare and … The problems in our
healthcare system are both pervasive and entrenched; thus, innovative approaches … Incorporating these
multiple perspectives allowed us to approach problems from different angles of vision … Many of the topics discussed in class opened my eyes to the problems with
our healthcare system.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/nursing-home/resources/infotransNHSOPS.pdf
January 01, 2010 - training to help staff work effectively with residents who are hard to care
for or who have behavioral problems—spit … when a resident is
harmed, the supervisor/administrator simply blames staff instead of investigating problems … It is easy for staff to speak up about problems in this nursing home. … about this item: “To
speak up” means to notify someone in authority [managers/supervisors] about the problems … My supervisor pays attention to resident safety problems in this nursing home.
1 Adapted from Zohar
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/infotranshsops.pdf
September 01, 2009 - My supervisor/manager overlooks patient safety problems that happen over and over. … We have patient safety problems in this unit. (negatively worded)
6. … Problems often occur in the exchange of information across hospital units. … (negatively worded) (More about
this item: Shift changes cause problems for patients in this hospital—problems
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www.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T2-Talking_with_Residents_Family_Members_Final.pdf
October 01, 2016 - ”
– Taking antibiotics when they are not needed may cause health problems. … – Taking antibiotics when they are not needed may cause health problems. … • Although we cannot be certain that any of these harms or problems will occur, it is important
to … • There are five potential health problems that occur as a result of taking an antibiotic:
1. … antibiotic-resistant infections
• Other drugs that your family member takes, such as Coumadin®
• Health problems
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www.ahrq.gov/sops/international/hospital/translators.html
October 01, 2014 - My supervisor/manager overlooks patient safety problems that happen over and over. … We have patient safety problems in this unit. (negatively worded)
6. … Problems often occur in the exchange of information across hospital units. … (negatively worded) ( More about this item: Shift changes cause problems for patients in this hospital—problems
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/01-ASC-webcast-2023-0509-intro.pdf
January 01, 2023 - ET
Webcast Technical Info
• Audio issues
• Poor Connection
• Use Q&A: For Questions or Other Problems
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-ch-hospital-webcast-122223-intro.pdf
June 02, 2025 - ET
Webcast Technical Info
• Audio issues
• Poor Connection
• Use Q&A: For Questions or Other Problems
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apa_bpd.pdf
June 02, 2025 - ■ Damaged lung tissue causes
breathing and health problems.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc_pilotstudy.pdf
April 01, 2015 - We make improvements when someone points out patient safety problems. 93% 94%
C6. … We make improvements when someone points out patient safety problems. 93% 93%
C6. … We are good at changing processes to make sure the same patient safety problems don’t happen
again. … We make improvements when someone points out patient safety
problems.
95% 96% 91% 91%
C6. … We make improvements when someone points
out patient safety problems. 98% 96% 98% 91% 91% 90%
C6.
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www.ahrq.gov/sites/default/files/2024-01/savage-report.pdf
January 01, 2024 - Computer problems appeared to cause the greatest degree of
deviation from the normal task. … Other deviations included problems with technical support
(availability of technical support staff), … The
remaining 9% indicated that the workaround actually created additional problems. … [probe to clarify problems/solutions]
For each problem/solution, ask how frequently it occurs.
2. … [probe to expand on impact or clarify – e.g., do they notice when problems are
occurring?]
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/observation-slides.html
June 01, 2017 - Direct observation helps the supervisor see problems (undesired gaps between intention and actual practice … Consider huddle only for unit leaders to discuss problems touching multiple parts of the facility (e.g
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-November_45.pdf
January 01, 2007 - incident reporting cards identifying obstacles to care, injuries or extended
hospitalizations, and problems … Nurses on the unit reported problems
they encountered during their shift to the resource nurse. … • Quality problems that did not meet the definition of AE or near miss were classified
separately … For example, quality problems (other than AEs and potential AEs) occurred when
appropriate instruments … Additionally the types of
problems encountered, specifically in obstetrics, are often different from
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www.ahrq.gov/patient-safety/diagnostic-excellence-grants/index.html
February 01, 2025 - Diagnostic Center of Excellence is to shift the current focus on the clinician as the center of both the problems … - 09/29/26 Goals: The goal of the ADVANCE Diagnostic Center of Excellence is to tackle diagnostic problems … Project Aims: Identify current evidence, diagnostic practices, and outcomes for the problems of unintentional … Develop recommendations for improved diagnostic practices for the clinical problems above, based on analysis
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www.ahrq.gov/ncepcr/tools/workforce-financing/case-example-7.html
July 01, 2019 - Cherokee providers believe that social needs cause behavioral health problems, and that they must consider … Patients often go into the exam room with multiple problems. … The BHCs consider it their job to distill those problems into something that is workable, that patients … CHC supervisors meet to identify patterns of care delivery that are not working and solve problems. … This culture allows individuals to work on problems.
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/reports-and-case-studies/CaseStudyPatientExperience_July2011FINAL_revised20110728.pdf
July 01, 2011 - that asks patients if they received easy to understand
instructions about taking care of their health problems … service and access to care were below the faculty practice group
average, confirming the suspected problems … Throughout this process, some of the problems uncovered included
patients abandoning phone calls after … Through this internal review, the practice determined the problems in access and
customer service were … In addition to training, staffing was adjusted to address workflow and management
problems.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects.pptx
December 01, 2017 - Ask them why these problems are occurring and where the problems reside. … ASK:
What are the problems?
What might the solutions be? … We wind up building workarounds to overcome poor system problems. … That is essential to learning what is happening on the floor and to identifying the problems. … ASK:
What can we do to fix these problems?
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-analysis-program-intro-slides.pdf
November 19, 2020 - ► Log out and log back in
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