-
www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-5.html
June 01, 2023 - learning from patients and families about diagnostic mishaps—their origins, impact, and longer term consequences—to
-
www.ahrq.gov/sites/default/files/2025-02/woods2-report.pdf
January 01, 2025 - list of benefits of a hazard evaluation program: fewer accidents over the life of a process,
reduced consequences … (frequency)
• What are the consequences? … on grouping failure events by causes,
physical characteristics, and the potential for severity of consequences … cognitive-social-emotional immaturity, limited
communication skills, and constrained ability to understand the impact or consequences … : fail-points lead to the occurrence of an event, which results in an
outcome (a level of harm or consequences
-
www.ahrq.gov/sites/default/files/2025-02/holl-report.pdf
January 01, 2025 - system, including
an evidence-based safety intervention, may introduce unintended and unanticipated consequences … analytic method that (1) predicts how and where processes may fail and result in significant detrimental
consequences … useful: (1) improvements that help prevent the failure mode are better than those that mitigate the
consequences … Risk Matrix for Safeguard Category S3
Safeguard Effectiveness Category S3
FREQUENCY CONSEQUENCES
C0
-
www.ahrq.gov/news/blog/ahrqviews/eliminate-diagnostic-errors.html
August 01, 2022 - Too many Americans have experienced the health-related consequences and anxieties that follow a diagnostic
-
www.ahrq.gov/research/findings/nhqrdr/nhqdr16/looking-forward.html
June 01, 2018 - some measures carry more significance than others as they affect more people or have more significant consequences … knowledge base of substance use and provides recommendations to address substance misuse and related health consequences
-
www.ahrq.gov/news/newsroom/case-studies/coe0503.html
October 01, 2014 - with or without developmental disabilities or underlying conditions that predispose to OME and its consequences
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-235-fullreport.pdf
September 01, 2018 - Unintended consequences: What are the potential unintended consequences of reporting at
this level of … Unintended consequences: What are the potential unintended consequences of reporting at
this level of … Unintended consequences: What are the potential unintended consequences of reporting at
this level of … Unintended consequences: What are the potential unintended consequences of reporting at
this level of … Unintended consequences: What are the potential unintended consequences of reporting at
this level of
-
www.ahrq.gov/evidencenow/projects/alcohol/index.html
October 01, 2024 - In addition, unhealthy alcohol use has detrimental socioeconomic consequences, with an estimated annual
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-229-fullreport.pdf
February 01, 2018 - Unintended consequences: What are the potential unintended consequences of reporting at
this level of … Unintended consequences: What are the potential unintended consequences of reporting at
this level of … Unintended consequences: What are the potential unintended consequences of reporting at
this level of … Unintended consequences: What are the potential unintended consequences of reporting at
this level of … Unintended consequences: What are the potential unintended consequences of reporting at
this level of
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/leveraging-cultural-change-080814.pptx
January 01, 2013 - Safety and Assessment of Harm
7
Believe that failure to follow guidelines may cause harm
Built in alerts
Consequences … 8
Safety and Urinary Catheters
9
Seat Belt Yes No
Believe in it x
Built in safety alerts x
Consequences … Built in safety alerts x
Consequences ?
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/duration/chipra-154-fullreport.pdf
July 01, 2018 - Unintended consequences: What are the potential unintended consequences of reporting at
this level of … Unintended consequences: What are the potential unintended consequences of reporting at
this level of … Unintended consequences: What are the potential unintended consequences of reporting at
this level of … Unintended consequences: What are the potential unintended consequences of reporting at
this level of … Unintended consequences: What are the potential unintended consequences of reporting at
this level of
-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-based-reports/services/quality/patientsftyupdate/ptsafetysum.pdf
March 01, 2013 - Some patient safety practices
(PSPs) have resulted in unintended consequences, whereas
others have … Accordingly, this report emphasizes matters
of context and generalizability, as well as unintended
consequences … Evidence on potential for harmful unintended
consequences. … Strength of
Evidence for
Effectiveness
of the PSPs
Evidence
or Potential
for Harmful
Unintended
Consequences … Evidence or potential for harmful unintended consequences: negligible, low, moderate, or high.
-
www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care-2/tools.html
July 01, 2023 - situation (D), expressing concerns about the events (E), suggesting alternative actions (S), stating consequences
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-0176-fullreport.pdf
September 01, 2019 - Unintended consequences: What are the potential unintended consequences of reporting at
this level … Unintended consequences: What are the potential unintended consequences of reporting at
this level … Unintended consequences: What are the potential unintended consequences of reporting at
this level … Unintended consequences: What are the potential unintended consequences of reporting at
this level … Unintended consequences: What are the potential unintended consequences of reporting at
this level
-
www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-3.html
June 01, 2023 - systems do take that make matters worse for patients and their families. 23,24
Conversely, the negative consequences … involving perceived diagnostic failures, it becomes clear that diagnostic mishaps also have persisting consequences … how many years earlier the adverse event occurred makes it possible to construct a profile of how the consequences … Since mishaps with minor consequences are more likely forgotten than those with large impact, recall … questions should be designed to provide information about both the emergence of the problem and its consequences
-
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-3.html
June 01, 2023 - systems do take that make matters worse for patients and their families. 23,24
Conversely, the negative consequences … involving perceived diagnostic failures, it becomes clear that diagnostic mishaps also have persisting consequences … how many years earlier the adverse event occurred makes it possible to construct a profile of how the consequences … Since mishaps with minor consequences are more likely forgotten than those with large impact, recall … questions should be designed to provide information about both the emergence of the problem and its consequences
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-134-fullreport.pdf
November 01, 2019 - Unintended consequences: What are the potential unintended consequences of reporting at
this level of … Unintended consequences: What are the potential unintended consequences of reporting at
this level of … Unintended consequences: What are the potential unintended consequences of reporting at
this level of … Unintended consequences: What are the potential unintended consequences of reporting at
this level of … Unintended consequences: What are the potential unintended consequences of reporting at
this level of
-
www.ahrq.gov/research/findings/studies/index.html?page=479
January 01, 2024 - aimed to identify the factors associated with hospitals' decisions to adopt robotic technology and the consequences … Communication, Medical Liability, Patient Safety
Cochran G , Field C , Caetano R Injury-related consequences … This study identifies latent classes of intervention recipients based on injury-related consequences … Injury-related consequences of alcohol misuse among injured patients who received screening and brief
-
www.ahrq.gov/research/findings/studies/index.html?page=480
January 01, 2024 - aimed to identify the factors associated with hospitals' decisions to adopt robotic technology and the consequences … Communication, Medical Liability, Patient Safety
Cochran G , Field C , Caetano R Injury-related consequences … This study identifies latent classes of intervention recipients based on injury-related consequences … Injury-related consequences of alcohol misuse among injured patients who received screening and brief
-
www.ahrq.gov/teamstepps-program/curriculum/mutual/overview/index.html
July 01, 2023 - CUS
CUS is an acronym for three assertive statements:
DESC (Describe, Express, Suggest, Consequences