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Showing results for "problems".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33881/psn-pdf
    August 01, 2019 - 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

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33793/psn-pdf
    November 01, 2015 - So you almost are hardwiring some problems into routine care by saying medication reconciliation has … , and then there are also the deeper levels of problems related to communication and teamwork. … So you have surgical problems, medication problems, diagnostic problems, infections, and so on. … But, you would still have all the other medication problems and tons of nonmedication problems. … Once you're pretty sure what the problems are, it makes more sense to measure those problems.

  3. Alcohol-Misuse Research-Protocol (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/pdf/alcohol-misuse_research-protocol.pdf
    April 28, 2010 - ; or use continues despite persistent social or interpersonal problems. … and secondary prevention of alcohol problems by using screening and brief interventions in primary … Rapid Alcohol Problems Screen (RAPS). … Screening and intervention for alcohol problems. … Screening for alcohol problems in primary care: a systematic review.

  4. 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

  5. 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

  6. 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

  7. 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.

  8. Closing the Feedback Loop to Improve Diagnostic Quality - Final Report (pdf file)

    digital.ahrq.gov/sites/default/files/docs/citation/r18hs017060-weiss-final-report-2011.pdf
    January 01, 2011 - Results: Main Study: For phases 1 and 2 approximately 15% of problems were unresolved. … were still unresolved, or who had problems with their medications. … The revised process was piloted successfully and encountered only a few problems. … within a week of their acute care visit and many of the problems persist after three weeks … • Timely follow-up can be done and it can catch problems at an early stage.

  9. The Effects of Age, Cognition, and Health Literacy on Use of a Patient EMR - 2010 | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/effects-age-cognition-and-health-literacy-use-patient-emr/annual-summary/2010
    January 01, 2010 - the ability to use a patient portal of an EMR system, the study will identify the root of usability problems … and develop empirically-based interventions to help those who are most likely to face problems interacting … as age, cognitive abilities, health literacy, and task performance. ( Ongoing ) Identify usability problems

  10. Results of an enhanced clinic handoff and resident education on resident patient ownership and patient safety. | PSNet

    psnet.ahrq.gov/issue/results-enhanced-clinic-handoff-and-resident-education-resident-patient-ownership-and-patient
    March 28, 2018 - March 28, 2018 Problems after discharge and understanding of communication with their … Admission handoff communications: clinician's shared understanding of patient severity of illness and problems … More About The Topic Hospitals Educators Medicine Discontinuities, Gaps, and Hand-Off Problems

  11. Patient Health Questionnaire (PHQ-9) (pdf file)

    www.uspreventiveservicestaskforce.org/home/getfilebytoken/sDvjG49sFm7t3f3CnZUuFw
    October 04, 2005 - QUESTIONNAIRE (PHQ-9)DATE:NAME:Over the last 2 weeks, how often have you beenbothered by any of the following problems … Not difficult at allIf you checked off any problems, how difficulthave these problems made it for you

  12. Post-implementation optimization of medication alerts in hospital computerized provider order entry systems: a scoping review. | PSNet

    psnet.ahrq.gov/issue/post-implementation-optimization-medication-alerts-hospital-computerized-provider-order-entry
    December 31, 2014 - 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

  13. A comparative review of patient safety initiatives for national health information technology. | PSNet

    psnet.ahrq.gov/issue/comparative-review-patient-safety-initiatives-national-health-information-technology
    November 03, 2015 - 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

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41847/psn-pdf
    November 28, 2012 - quality improvement collaboratives have been used to successfully address a variety of patient safety problems … authors speculate that the collaborative approach may be useful for more specific, targeted safety problems

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49771/psn-pdf
    July 01, 2016 - In a study of medication errors facilitated by CPOE, researchers identified 18 fundamental problems … in CPOE systems.(5) Subsequently, usability experts traced 12 of the 18 problems https://psnet.ahrq.gov … These poor interfaces transform old problems into new ones; they eliminate the problem of illegible … .(15) Such monitoring might have identified this and related problems prior to their being discovered … Ironies of automation: increasing levels of automation can increase, rather than decrease, the problems

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36544/psn-pdf
    July 14, 2010 - 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

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38291/psn-pdf
    April 08, 2011 - united-states Analysis of closed malpractice claims has been used to identify patterns of errors and system problems … Problems in telephone triage were also a common underlying factor.

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37530/psn-pdf
    December 15, 2008 - do-medical-inpatients-who-report-poor-service-quality-experience-more- adverse-events-and Prior research has demonstrated that problems … While patients tend to identify these issues when surveyed about problems they perceive with the quality

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42473/psn-pdf
    August 13, 2013 - This systematic review found that equipment problems account for a large proportion of operating room … As the majority of equipment problems were due to potentially preventable issues (such as equipment

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41860/psn-pdf
    November 28, 2012 - stakeholder-perspectives-handovers-between-hospital-staff-and-general- practitioners Although seminal studies have documented persistent problems … including readmissions and adverse events after discharge, understanding of the basic mechanisms of these problems
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