AHRQ Search | Home Page

Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression | PSNet

psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression

May 26, 2021 - Case Objectives Describe risks associated with intravenous opioid administration through patient-controlled … Best Practices in Opioid PCA Use Due to the significant risks of mortality and morbidity associated … Additional risks include activation of PCA by others (usually well-meaning family, or “PCA by proxy”) … Council Tool Kit 2009. 27 Implementation of standardized PCA order sets has been shown to mitigate risks … WebM&M Cases Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks

Look-alike and sound-alike medicines: risks and 'solutions.' | PSNet

psnet.ahrq.gov/issue/look-alike-and-sound-alike-medicines-risks-and-solutions

March 29, 2023 - Commentary Look-alike and sound-alike medicines: risks and 'solutions.' … Look-alike and sound-alike medicines: risks and 'solutions'. … Look-alike and sound-alike medicines: risks and 'solutions'.

The risks to patient safety from health system expansions. | PSNet

psnet.ahrq.gov/issue/risks-patient-safety-health-system-expansions

May 13, 2020 - Commentary Emerging Classic The risks to patient safety … The Risks to Patient Safety From Health System Expansions. … The Risks to Patient Safety From Health System Expansions. … July 7, 2021 A framework for operationalizing risk: a practical approach to patient safety

The Risks of a Malpositioned Gastrostomy Tube and Poor Communication | PSNet

psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication

August 01, 2012 - SPOTLIGHT CASE The Risks of a Malpositioned Gastrostomy Tube and Poor Communication … The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet]. … The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet]. … Best practices to mitigate patient care transition risks are to minimize the number of provider transitions … The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet].

Preventing errors with high-risk medications. | PSNet

psnet.ahrq.gov/issue/preventing-errors-high-risk-medications

May 20, 2020 - Newspaper/Magazine Article Preventing errors with high-risk medications. … Citation Text: Preventing errors with high-risk medications. Wiley F. Drug Topics. … Cite Citation Citation Text: Preventing errors with high-risk … June 16, 2019 A medication safety education program to reduce the risk of harm caused

Risk Management Pearls for Medication Safety: Part I and Part II. | PSNet

psnet.ahrq.gov/issue/risk-management-pearls-medication-safety-part-i-and-part-ii

September 30, 2015 - Citation Text: Risk Management Pearls for Medication Safety: Part I and Part II. … Chicago, IL: American Society for Healthcare Risk Management; 2014. … These guides cover medication safety principles, common causes for errors, and strategies to manage risks … Chicago, IL: American Society for Healthcare Risk Management; 2014. … February 17, 2009 Reducing the Risks of Wrong-Site Surgery: Safety Practices from The

Fires during surgeries a bigger risk than thought. | PSNet

psnet.ahrq.gov/issue/fires-during-surgeries-bigger-risk-thought

August 24, 2016 - Newspaper/Magazine Article Fires during surgeries a bigger risk than thought. … Citation Text: Fires during surgeries a bigger risk than thought. Kowalczyk L. Boston Globe. … Cite Citation Citation Text: Fires during surgeries a bigger risk … September 26, 2012 When surgery goes wrong: weighing up the risks.

Radiologist age and diagnostic errors. | PSNet

psnet.ahrq.gov/issue/radiologist-age-and-diagnostic-errors

March 02, 2022 - overall mean error rate for all radiologists was low (0.5%), increasing age was associated with increased relative … risk of diagnostic errors. … January 13, 2021 Physician task load and the risk of burnout among US physicians in a

Healthcare industry representatives: maximizing benefits and reducing risks. | PSNet

psnet.ahrq.gov/issue/healthcare-industry-representatives-maximizing-benefits-and-reducing-risks

March 18, 2010 - Magazine Article Healthcare industry representatives: maximizing benefits and reducing risks … Citation Text: Healthcare industry representatives: maximizing benefits and reducing risks. … This article addresses strategies for minimizing patient safety risks related to interactions with health … Citation Citation Text: Healthcare industry representatives: maximizing benefits and reducing risks … April 17, 2017 Perioperative medication errors: uncovering risk from behind the drapes

Suicide Prevention | PSNet

psnet.ahrq.gov/perspective/suicide-prevention

March 24, 2025 - In these controlled settings, the severity of suicide risk dictates whether rapid suicide risk mitigation … is essential on the day of discharge from in-patient psychiatric hospitalization in reducing future risks … example, tobacco and blood pressure screenings are routine in many healthcare settings to catch hidden risks … . 1,2 It is what we call incidental risk, or sometimes people call it occult risk, meaning it was hidden … For example, with a person who has mild risk, we cannot ignore the risk, but they probably do not need

Patient Safety in Frail Older Patients | PSNet

psnet.ahrq.gov/perspective/patient-safety-frail-older-patients

November 26, 2019 - Bed rest, hospitalization, and the testing and treatment patients receive come with a number of risks … . 4 Risk assessment of treatment Frail older patients are at risk of unintended consequences from procedures … in long-term care planning with the patient and/or family can reduce patient exposure to unnecessary risks … Care providers should consider both the risks of the proposed treatment and the long-term care goals … They all have common risk factors and those risk factors are frequently found in frail older patients

Identified safety risks with splitting and crushing oral medications. | PSNet

psnet.ahrq.gov/issue/identified-safety-risks-splitting-and-crushing-oral-medications

September 24, 2010 - Commentary Identified safety risks with splitting and crushing oral medications. … Identified safety risks with splitting and crushing oral medications. … Identified safety risks with splitting and crushing oral medications. … July 2, 2008 Failure mode and effects analysis: a useful tool for risk identification … October 3, 2011 High-alert medications: shared accountability for risk identification

Digital health technology-specific risks for medical malpractice liability. | PSNet

psnet.ahrq.gov/issue/digital-health-technology-specific-risks-medical-malpractice-liability

January 18, 2023 - Commentary Digital health technology-specific risks for medical malpractice liability … Digital health technology-specific risks for medical malpractice liability. … Digital health technology-specific risks for medical malpractice liability. … June 14, 2017 Deploying and measuring a risk and patient safety program. … July 1, 2013 View More See More About The Topic Hospitals Risk Managers

'Cyberloafing' in health care: a real risk to patient safety. | PSNet

psnet.ahrq.gov/issue/cyberloafing-health-care-real-risk-patient-safety

June 19, 2024 - Commentary 'Cyberloafing' in health care: a real risk to patient safety. … 'Cyberloafing' in Health Care: A Real Risk to Patient Safety. … The author suggests raising awareness of the risks associated with personal communication technology … 'Cyberloafing' in Health Care: A Real Risk to Patient Safety.

Detection of patient risk by nurses: a theoretical framework. | PSNet

psnet.ahrq.gov/issue/detection-patient-risk-nurses-theoretical-framework

September 24, 2010 - Commentary Detection of patient risk by nurses: a theoretical framework. … Detection of patient risk by nurses: a theoretical framework. … This article outlines a framework for nurses to promptly identify risks and prevent delays when a patient's … Detection of patient risk by nurses: a theoretical framework. … September 23, 2009 Risk, Safety and Reliability Special Issue.

Risk and Safety Management in Infertility and Assisted Reproductive Technology. | PSNet

psnet.ahrq.gov/issue/risk-and-safety-management-infertility-and-assisted-reproductive-technology

August 01, 2016 - Special or Theme Issue Risk and Safety Management in Infertility and Assisted Reproductive … Citation Text: Risk and Safety Management in Infertility and Assisted Reproductive Technology. … Introduction of assisted reproductive technology has led to new risks in reproductive medicine. … Linkedin Copy URL Cite Citation Citation Text: Risk … 24, 2013 Patient Safety in Obstetrics and Gynecology: Improving Outcomes, Reducing Risks

Risks in the implementation and use of smart pumps in a pediatric intensive care unit: application of the failure mode and effects analysis. | PSNet

psnet.ahrq.gov/issue/risks-implementation-and-use-smart-pumps-pediatric-intensive-care-unit-application-failure

March 09, 2022 - Study Risks in the implementation and use of smart pumps in a pediatric intensive … Risks in the implementation and use of smart pumps in a pediatric intensive care unit: application of … This study applied failure mode and effect analysis (FMEA) to identify possible risks associated with … Risks in the implementation and use of smart pumps in a pediatric intensive care unit: application of … September 19, 2016 Surgery is in itself a risk factor for the patient.

Perioperative medication errors: uncovering risk from behind the drapes. | PSNet

psnet.ahrq.gov/issue/perioperative-medication-errors-uncovering-risk-behind-drapes

March 27, 2018 - Newspaper/Magazine Article Perioperative medication errors: uncovering risk from … Citation Text: Perioperative medication errors: uncovering risk from behind the drapes. … The authors provide recommendations to reduce risks of error, including using barcode medication administration … Cite Citation Citation Text: Perioperative medication errors: uncovering risk … WebM&M Cases Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks

Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes. | PSNet

psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes

August 14, 2024 - At the conclusion of this educational activity, participants should be able to: Recognize the risk … There was no compelling need to complete a formal falls risk assessment as the history alone for these … two residents provides sufficient information to highlight their risk for future falls. … focused deprescribing especially of psychotropic medications and opioids, decreasing environmental risks … staff, enabling greater transparency, better communication, and greater awareness of patient safety risks

Investigating the association of alerts from a national mortality surveillance system with subsequent hospital mortality in England: an interrupted time series analysis. | PSNet

psnet.ahrq.gov/issue/investigating-association-alerts-national-mortality-surveillance-system-subsequent-hospital

October 20, 2021 - national hospital mortality surveillance system that generates monthly mortality alerts) and trends in the relative … risk of mortality across National Health Service hospital trusts. … On average, mortality risk decreased after a trust received a mortality alert. … A past PSNet perspective discussed the use of risk-adjusted mortality as part of a safety measurement

Search AHRQ

Results