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  1. www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/pdsa-form.html
    June 01, 2017 -   Do: Describe what actually happens when we run the test (note any unexpected events or problems …   Do:   Describe what actually happens when we run the test (note any unexpected events or problems
  2. Module 2: Example (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/huddles/example-pdsa-form.docx
    May 01, 2017 - Do: Describe what actually happens when we run the test (note any unexpected events or problems … Do: Describe what actually happens when we run the test (note any unexpected events or problems
  3. www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-150-metabolic-monitoring-testing-summary.pdf
    December 31, 2015 - gain (Correll et al.,2009), diabetes (Andrade et al. 2011; Bobo et al., 2013) and cardiovascular problems … Research also suggests that metabolic problems in childhood and adolescence are associated with poor
  4. www.ahrq.gov/hai/cusp/modules/engage/alt-text.html
    April 01, 2013 - Slide 10 Supports Both Technical and Adaptive Work of Change Technical Work Addresses problems … Slide 11 Supports Both Technical and Adaptive Work of Change Adaptive Work Addresses problems
  5. www.ahrq.gov/patients-consumers/diagnosis-treatment/hospitals-clinics/10-tips/index.html
    June 01, 2018 - A free 11-minute DVD provides video excerpts of 50 actual chest tube insertions to illustrate problems … Ordering information for Problems and Prevention: Chest Tube Insertion (AHRQ Publication No. 06-0069
  6. www.ahrq.gov/talkingquality/translate/web/pathways/composites.html
    May 01, 2019 - more than four or five elements, letting people look at all them at once does not create cognitive problems
  7. www.ahrq.gov/evidencenow/projects/heart-health/research-results/videos/index.html
    September 01, 2021 - for improving primary care using external support is already being expanded to address other health problems
  8. www.ahrq.gov/patient-safety/settings/emergency-dept/discharge-process.html
    July 01, 2017 - vulnerabilities of patients at highest risk of frequent ED use; (b) the causes, dimensions, and effects of problems
  9. www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/app-e.html
    May 01, 2017 -              - Read back specimen labeling including patient's name Team Discusses: |___| Equipment problems
  10. www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospvaluepilotreport.pdf
    November 01, 2017 - Takes action to address workflow problems that are brought to his or her attention. 77% 4. … Takes action to address workflow problems that are brought to his or her attention. 75% 78% 80% 4. … Takes action to address workflow problems that are brought to his or her attention. 77% 69% 75% 87% … We are given opportunities to try out solutions to workflow problems. 56% 56% 58% 83% 64% 31 … We are given opportunities to try out solutions to workflow problems. 70% 63% 58% 58% 56% 64%
  11. www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalvaluepilotreport.pdf
    November 01, 2017 - Takes action to address workflow problems that are brought to his or her attention. 77% 4. … Takes action to address workflow problems that are brought to his or her attention. 75% 78% 80% 4. … Takes action to address workflow problems that are brought to his or her attention. 77% 69% 75% 87% … We are given opportunities to try out solutions to workflow problems. 56% 56% 58% 83% 64% 31 … We are given opportunities to try out solutions to workflow problems. 70% 63% 58% 58% 56% 64%
  12. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Borowitz_4.pdf
    January 22, 2008 - has been communicated during any patient care hand-off can be substantial.7, 8, 9, 10 Communication problems … had arisen while they were on call; whether those problems could have and should have been anticipated … Sign-out should focus on identifying anticipated problems and the appropriate plan of care for each, … • Selected demographics, problems, medications, and treatments should be characterized. … plans for those potential problems.
  13. www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/2023-ASC-Database-Report-II.pdf
    January 01, 2023 - (Item C1) 94% 94% 91% 92% 91% We make improvements when someone points out patient safety problems … (Item C4) 87% 84% 85% 84% 81% Staff are told about patient safety problems that happen in this facility … (Item C4) 86% 98% 82% 97% 95% 80% 78% 71% 76% Staff are told about patient safety problems that … (Item C1) 95% 93% 91% 94% We make improvements when someone points out patient safety problems. … (Item C4) 92% 84% 79% 90% Staff are told about patient safety problems that happen in this facility
  14. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_4_PPT_508.pptx
    April 01, 2011 - hospital-acquired infections, and procedural complications Many complications can be attributed to problems … Many of these complications can be attributed to discharge planning problems, including medication changes … Patients and families typically do not look to hospital staff to solve their home and family problems … Discuss with the patient and family 5 key areas to prevent problems at home Describe what life at home … Highlight warning signs and problems: Identify warning signs or potential problems.
  15. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Bayley.pdf
    January 01, 2004 - more basic technical, structural, and cultural challenges that affect the ability of IT to solve the problems … IDSs), with a particular focus on the use of information technology (IT) to help address transition problems … • What patient safety problems arise due to ineffective transitions across care settings? … The promise and challenges of clinical IT The FMEA demonstrates that IT can help solve problems of … Elderly patients’ problems with medication: an in-hospital and follow- up study.
  16. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Seagull_98.pdf
    April 07, 2008 - Our approach has been to identify strategic areas for which solutions to problems would be significant … likelihood increases that a surgeon will have familiarity with a multiplicity of patient-specific problems … Inefficiency, redundancy, communication problems, usage problems, and system failures are among the … quantitative, valid measures of workflow within patient-surgeon interfaces, identifying ergonomic problems … Systemwide problems can be identified and root causes discovered.
  17. www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/trends.html
    June 01, 2018 - Reaching agreement on problems and plans. Providing closure ( Dean, et al., 2014 ).
  18. www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/app-f.html
    May 01, 2017 - | Before the patient leaves the room, will ALL members of the surgical team discuss any equipment problems
  19. www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-moving-forward-intro-slides.pdf
    October 12, 2017 - • Other problems?
  20. www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-cancer-care-intro-fry.pdf
    June 13, 2017 - • Other problems?

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