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psnet.ahrq.gov/issue/benefits-and-risks-including-patients-rca-teams
May 02, 2018 - Newspaper/Magazine Article
Benefits and risks of including patients on RCA teams. … Citation Text:
Benefits and risks of including patients on RCA teams. … Copy URL
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Benefits and risks … June 30, 2021
Epidural-IV route mix-ups: reducing the risk of deadly errors. … May 2, 2018
Don't underestimate the impact of change on risk potential.
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psnet.ahrq.gov/issue/use-temporary-names-newborns-and-associated-risks
December 21, 2017 - Study
Use of temporary names for newborns and associated risks. … Use of Temporary Names for Newborns and Associated Risks. … Use of Temporary Names for Newborns and Associated Risks. … December 21, 2017
Risk of wrong-patient orders among multiple vs singleton births in … 2012
Patient misidentification in the neonatal intensive care unit: quantification of risk
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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
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Preventing errors with high-risk … June 16, 2019
A medication safety education program to reduce the risk of harm caused
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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
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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].
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psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx
Spotlight … The Risks of a Malpositioned Gastrostomy Tube and
Poor Communication
Source and Credits
• This … Suggest possible solutions to improve interprofessional and interfacility
communication.
3
THE RISKS … COMMUNICATION
A case highlighting the importance of clear documentation of
complications, mitigating risks … Best practices to mitigate patient care transition risks are to minimize the number of provider
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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
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Fires during surgeries a bigger risk … September 26, 2012
When surgery goes wrong: weighing up the risks.
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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
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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.
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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
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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'.
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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
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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
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Hospitals
Risk Managers
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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
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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.
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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.
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psnet.ahrq.gov/issue/data-catalyst-change-stories-frontlines
July 28, 2023 - J Healthc Risk Manag. 2015;34(3):18-25. doi:10.1002/jhrm.21161. … J Healthc Risk Manag . 2015; 34 (3) :18-25 .
View more articles from the same authors. … J Healthc Risk Manag. 2015;34(3):18-25. doi:10.1002/jhrm.21161. … View More
Related Resources
Digital health technology-specific risks … December 7, 2022
Deploying and measuring a risk and patient safety program.
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psnet.ahrq.gov/web-mm/challenging-case-multiple-suicide-attempts-complex-patient-psychiatric-comorbidities
September 27, 2023 - Assessing suicide risk
The risk of suicide is increased in people with syndromal major depressive disorder … Patients with several of these risk factors are at significantly increased risk of suicide attempts … , so it is useful to tally these risk factors as part of suicidal ideation risk stratification . … assessment remains frustratingly imprecise. 13 As illustrated in this case, the risks of inadequate … social-occupational functioning; the benefits of medication treatment almost always outweigh these risks
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psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-cesarean-deliveries
July 23, 2024 - births. 2 While cesarean delivery may be the safest option in certain births, in others, the risks … Risks to maternal health that are associated with cesarean births include infection, anesthesia-related … risks, blood loss, blood clots, and longer recovery periods (i.e., risks associated with any major surgery … may outweigh the benefits for low-risk births. … August 9, 2006
New practices reduce childbirth risks.
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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