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psnet.ahrq.gov/issue/examination-opportunities-active-patient-improving-patient-safety
October 04, 2011 - Surgical checklist implementation project: the impact of variable WHO checklist compliance on risk-adjusted … 2012
Surgical adverse outcomes and patients’ evaluation of quality of care: inherent risk
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psnet.ahrq.gov/issue/medical-liability-climate-and-prospects-reform
September 29, 2017 - "Sorry" is never enough: how state apology laws fail to reduce medical malpractice liability risk … April 21, 2015
Conditions that influence the impact of malpractice litigation risk on
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psnet.ahrq.gov/node/33810/psn-pdf
June 01, 2016 - CPPS content includes culture, leadership,
external influences, risk identification and analysis, data … management, systems design, mitigating risk
through systems thinking and design, and human factors
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psnet.ahrq.gov/issue/use-audit-feedback-implementation-strategy-promote-medication-error-reporting-nurses
March 24, 2021 - A machine learning-based clinical decision support system to identify prescriptions with a high risk … Resources
Patient Safety Innovations
Combined Proactive Risk
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psnet.ahrq.gov/node/38035/psn-pdf
September 03, 2008 - Risk Management Reporter. August 2008;27:1-10.
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psnet.ahrq.gov/node/37321/psn-pdf
February 03, 2011 - the methicillin-resistant Staphylococcus aureus (MRSA) bacterium, identifies
causes of infection and risk
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psnet.ahrq.gov/node/42126/psn-pdf
November 30, 2016 - November 30, 2016
Chicago, IL: American Society for Healthcare Risk Management; 2015.
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psnet.ahrq.gov/perspective/conversation-suchi-saria-phd
March 27, 2024 - they're taking advantage of the electronic health record (EHR) to implement systems for detecting at-risk … your sense of how AI is doing in radiology, dermatology, pathology, and fields like that, and what risks … So scanning retinal images to identify risk of diabetic retinopathy is a good example where people are … It has to be a combination of rigorously validated careful risk analysis and deep understanding of what's
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psnet.ahrq.gov/node/36250/psn-pdf
February 06, 2019 - resilience-engineering-concepts-and-precepts
This book explores how organizations and individuals must anticipate risk
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.146_slideshow.ppt
March 01, 2007 - HRC Risk Analysis: Pharmacy and Medications 1. Plymouth Meeting, PA: ECRI; November 2004. … Accident Precursor Analysis and Management: Reducing Technological Risk Through Diligence. … nursing units found that higher reporting rates were correlated with unit members’ perception of the risk … HRC Risk Analysis: Pharmacy and Medications 1. Plymouth Meeting, PA: ECRI; November 2004.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.137_slideshow.ppt
November 01, 2006 - impact of the Quality Counts program in Wisconsin found that hospitals involved in public reporting of risk-adjusted … Reporting
Comparing outcomes across institutions hampered by real and perceived challenges of carrying out risk … stroke or COPD is neglected
Unintended Consequences: Indirect Harm
Hospitals may turn away high-risk … such as mortality or complications are being compared, hospital will have higher scores with lower-risk
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psnet.ahrq.gov/node/33870/psn-pdf
November 01, 2018 - hospital is full and patients with better insurance are being
blocked out) or because the system bears risk … to me the CCP model seems like a good idea for a small, very select group of patients at the highest risk … majority of the inpatients are cared for by hospitalists, while a
few patients—those at the greatest risk … Redesigning care for patients at increased hospitalization risk: the
Comprehensive Care Physician model
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psnet.ahrq.gov/web-mm/ruptured-heterotopic-pregnancy
August 16, 2023 - the patient's appearance (hypothermic, tachycardic, and hypotensive), felt the patient was at high risk … to 1%-3% ( 4,5 ), largely due to the presence of multiple embryos in a given cycle and the increased risk … The high risk of an ectopic pregnancy with ART (3%-5%) mandates early ultrasound (4 weeks post-transfer … ectopic pregnancies, they should be trained in early pregnancy scans and be aware of the increased risk
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psnet.ahrq.gov/node/42701/psn-pdf
June 27, 2018 - relates how root cause analysis, typically used after an adverse event, can be utilized as a
proactive risk
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psnet.ahrq.gov/node/35521/psn-pdf
April 26, 2012 - highlights Canadian experiences in several safety-related areas: culture shift in support
of safety, risk
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psnet.ahrq.gov/node/33959/psn-pdf
January 17, 2012 - steps of the HFMEA process, and how to apply the technique to address the Joint
Commission proactive risk
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psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-patient-safety
May 01, 2012 - was valuable in the early days of the patient safety field by highlighting the major patient safety risks … But, newer work is using triggers themselves to identify patients at risk for various adverse events, … If people experience a minor event, does that increase their risk of other events? … you experience an inpatient adverse drug event, you increase not only your mortality but also your risk … of not only having another during the hospitalization, but I am also at increased risk of dying during
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psnet.ahrq.gov/node/36652/psn-pdf
February 14, 2007 - issue/smart-pumps-advanced-capabilities-and-continuous-quality-improvement
The author discusses high-risk
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psnet.ahrq.gov/node/34123/psn-pdf
November 02, 2014 - This patient fact sheet outlines
practical tips to minimize risk.
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psnet.ahrq.gov/node/36677/psn-pdf
February 21, 2007 - innovative medication safety initiatives:
use of color-coded storage bins and a venothromboembolism risk