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psnet.ahrq.gov/node/836757/psn-pdf
March 16, 2022 - improving-communication-and-teamwork-during-labor-feasibility-acceptability-
and-safety-study
Labor and delivery is a high-risk
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psnet.ahrq.gov/node/47091/psn-pdf
March 19, 2019 - provider-interruptions-and-patient-perceptions-care-observational-study-emergency-department
https://psnet.ahrq.gov/issue/association-interruptions-increased-risk-and-severity-medication-administration-errors
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psnet.ahrq.gov/perspective/conversation-richard-platt-md-msc
October 01, 2016 - providing clinicians and managers immediate feedback in some ways illustrating that a patient is at risk … We could build systems that would make it much easier to identify patients who are at risk for problems … vendor recounted the story of one physician who was shown an algorithm that predicted a high readmission risk … He asked a data scientist if he should prescribe fewer medications to reduce this risk. … learning algorithm found a significant correlation between the number of medications and readmission risk
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psnet.ahrq.gov/node/33857/psn-pdf
July 01, 2012 - The same is
true to a lesser extent for the somewhat more risk-bearing versions of ACOs. … If risk-based payment had been widespread, the HITECH Act would have
been unnecessary. … When you are at risk and you do adopt a cost-minimization strategy and you work up
the chain of causation … So if you were risk averse you would go to Epic, especially if you
were big. … what should be put
in on a radiology order slip: 75-year-old patient with chest pain and multiple risk
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psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - Each
RSI case is essentially a result of human error (or device failure) in a complex and high-risk … when possible, but the decision to remove a
retained fragment is based on the clinician weighing the risk … of harm from leaving the fragment where it is
versus the risk of harm from trying to retrieve the fragment … When it is determined after
discovery of an RSI that the risk of retention exceeds the risk of removal … Risk factors and preventive strategies for unintentionally
retained surgical sharps: a systematic review
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psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
February 05, 2020 - the patient survives the episode of hypoxemia. 1 Anesthesia clinicians are very aware of the enormous risk … of the routine anesthesia machine check-out procedure at the beginning of every working day. 3 The risk … operating room infrastructure because of the high cost of constructing a separate pipeline system and the risk … This new technology effectively eliminates the risk of a hypoxic gas mixture in the breathing system … Systematic review and evaluation of physiological track and trigger warning systems for identifying at-risk
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psnet.ahrq.gov/node/33865/psn-pdf
September 01, 2018 - that staff will follow that
rule, it will be easy to follow that rule, and we can avoid any similar risks … dealing with individual incidents in health care environments, probably much more so than in other high-risk
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psnet.ahrq.gov/node/46502/psn-pdf
July 02, 2019 - A significant proportion of these prescriptions were
refilled, highlighting the risk of chronic use
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psnet.ahrq.gov/node/41414/psn-pdf
June 06, 2012 - Medication Practices high-alert medications and 30-day readmission were
associated with increased risk
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psnet.ahrq.gov/web-mm/duplicate-insulin-order
May 04, 2012 - The Institute for Safe Medical Practices (ISMP) categorizes insulin as a high-risk medication in acute … administration.( 3,4 )
Although insulin errors occur in all hospital settings, the ED is a particularly high-risk … sets; disabling previously defaulted medications in order sets; activating alerts on targeted and high-risk … Take-Home Points
Insulin is a high-risk medication and safe practice recommendations from the American … The emergency department is an area of high risk and having pharmacists physically present can decrease
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psnet.ahrq.gov/node/46314/psn-pdf
November 01, 2020 - prevalence-inappropriate-antibiotic-prescriptions-among-us-ambulatory-care-visits-2010-2011
https://psnet.ahrq.gov/issue/variability-antibiotic-use-across-nursing-homes-and-risk-antibiotic-related-adverse-outcomes
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psnet.ahrq.gov/node/851650/psn-pdf
July 26, 2023 - https://psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults-risk-hospital
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psnet.ahrq.gov/node/74039/psn-pdf
November 03, 2021 - J Healthc Risk Manag. 2021;41(2):9-17. doi:10.1002/jhrm.21456.
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psnet.ahrq.gov/node/45274/psn-pdf
July 20, 2016 - https://psnet.ahrq.gov/issue/patient-misidentification-neonatal-intensive-care-unit-quantification-risk
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psnet.ahrq.gov/node/836752/psn-pdf
March 16, 2022 - J Healthc Risk Manag. 2022;42(1):31-36.
doi:10.1002/jhrm.21500.
-
psnet.ahrq.gov/node/47633/psn-pdf
June 02, 2019 - manifestations-high-reliability-principles-hospital-units-varying-safety-profiles-
qualitative
High reliability principles from other high-risk
-
psnet.ahrq.gov/node/74845/psn-pdf
February 16, 2022 - care-transition-trauma-patients-processes-articulation-work-and-after-handoff
Care transitions can increase the risk
-
psnet.ahrq.gov/node/73416/psn-pdf
June 23, 2021 - This study identified four phases
of post-operative handoff associated with risk factors: pre-transfer
-
psnet.ahrq.gov/node/853974/psn-pdf
January 01, 2024 - psnet.ahrq.gov/issue/surgical-checklist-implementation-project-impact-variable-who-checklist-compliance-risk
-
psnet.ahrq.gov/node/47964/psn-pdf
May 15, 2019 - deaths-among-opioid-users-impact-potential-inappropriate-prescribing-
practices
Inappropriate opioid prescribing increases risk