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psnet.ahrq.gov/issue/finding-way-ask-doctors-tough-questions
August 17, 2016 - July 31, 2013
Doctors say patients who lie may put their health at risk.
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psnet.ahrq.gov/issue/joint-commission-journal-quality-and-patient-safety
May 24, 2015 - May 28, 2014
Journal of Patient Safety and Risk Management.
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psnet.ahrq.gov/node/47267/psn-pdf
September 05, 2018 - research has shown that inappropriate
medication alert overrides occur frequently and place patients at risk
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psnet.ahrq.gov/issue/revolutionary
September 07, 2016 - July 1, 2015
All can be lost: the risk of putting our knowledge in the hands of machines
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psnet.ahrq.gov/node/43712/psn-pdf
December 03, 2014 - with patient safety managers and
information technologists revealed a number of generalizable high-risk
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psnet.ahrq.gov/issue/hidden-dangers-outsourcing-radiology
December 19, 2007 - November 28, 2018
Latex: a lingering and lurking safety risk.
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psnet.ahrq.gov/issue/rxawareness
September 07, 2016 - The website offers videos and other resources to assist community-level efforts to reduce risk for
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psnet.ahrq.gov/node/46411/psn-pdf
April 12, 2019 - interrupted-when-data
Inaccurate medication reconciliation leads to medication discrepancies and places patients at risk
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psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
January 01, 2020 - patients
• Present with confusion, disorientation, lethargy, severe pain, severe distress,
or with high risk … The nurse appropriately triaged this patient as ESI-2 based on
vital sings, appearance, and high-risk … message with the sender
– Ensures the transferred information was received as intended
– Mitigates the risk … to improve triage accuracy,
expedite care, and monitor patients waiting to be seen to
reduce the risk
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psnet.ahrq.gov/node/33607/psn-pdf
September 27, 2022 - Patient Safety
Clinicians who have been involved in errors or serious safety events may be at increased risk … At the same time, burnt out clinicians are more at risk of making errors or of practicing unsafely. … cross-sectional study of 11,395 physicians, sleep-related
impairment and burnout showed to be independent risk … utilizing-a-systems-and-design-thinking-approach-for-improving-well-being-within-health-professions-education-and-health-care/
https://psnet.ahrq.gov//#11
https://psnet.ahrq.gov/issue/increased-risk-burnout-physicians-and-nurses-involved-patient-safety-incident
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psnet.ahrq.gov/web-mm/crossing-line
December 01, 2012 - catheterization should be avoided except in emergencies because it is associated with an increased risk … Several factors increase the risk of mechanical complications during CVC insertion. … Interventions that May Reduce the Risk of Complications 1. … Consider using an antibiotic impregnated catheter, especially if the institutional risk of infectious
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psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph-0
March 24, 2025 - RW : What do we know about risk factors for people being very traumatized from these events? … The literature has emphasized how patients value apologies and that it doesn't appear to increase the risk … Is there a risk that things will get worse again if we shift back toward a more accountability-focused … crime-and-punishment approach, and to be purely selfish, we need information so that we can manage risk
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psnet.ahrq.gov/web-mm/blind-spot
July 30, 2020 - Diagnostic Studies for POVL Screening for POVL after surgery is usually reserved for high-risk procedures … Data delineating specific risk factors are lacking, making the implementation of preventive measures … air filters for rapid infusion devices; consider an air-aspiration central venous catheter for high-risk … ION has many proposed risk factors, but none have been proven; thus, there are no evidence-based prevention
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psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
November 27, 2019 - any thoracic pathology might have preempted the code and potentially mitigated the need for a high-risk … An atriocaval shunt is quicker but has prohibitively high mortality risk. … correct presumptive coagulopathy, (2) adhere diligently to optimal procedural technique to minimize the risk … should focus on improving their technique of emergency thoracostomy tube insertion to minimize the risk
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psnet.ahrq.gov/node/49519/psn-pdf
September 01, 2006 - been shown to improve resident efficiency and the quality of
signouts (15), as well as to reduce the risk … Although each signout
introduces risk, the strategies outlined above can improve the processes for signouts … Patients are at risk for errors due to discontinuity and signouts. … Does housestaff discontinuity of care increase
the risk for preventable adverse events?
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psnet.ahrq.gov/node/49648/psn-pdf
March 01, 2012 - The Centers for Medicare & Medicaid Services now publicly report hospitals' risk-
adjusted 30-day readmission … an independent intervention
are of poor methodological quality, with low patient numbers and high risk … //#references
phone calls to decreased readmissions, some programs may choose to target only high-risk … Reduction of 30-day postdischarge hospital readmission
or emergency department (ED) visit rates in high-risk
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psnet.ahrq.gov/node/74691/psn-pdf
January 01, 2021 - Infections and neurologic
conditions were the most missed diagnoses across all high-risk cohorts (16 … Healthcare organizations may find
a review of selected high-risk records useful to inform improvement … health professionals who care for patients, as well as safety analysts
and healthcare quality and risk … the work can be embedded into an existing patient safety program with
patient safety specialists or risk
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psnet.ahrq.gov/node/49624/psn-pdf
May 01, 2011 - Due to concerns of legal liability, the hospital administration and the risk management department at … fairness of our tort system.(14) In this case, fear of malpractice lawsuit may have motivated the
risk … These discussions require careful planning with quality and risk
management specialists at both hospitals … ,
o Consider using the word "error" or "mistake", after consultation with a disclosure coach or risk
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psnet.ahrq.gov/perspective/conversation-shantanu-agrawal-md-mphil
February 26, 2025 - Recently, we have started looking at social risk adjustment as an area that measurement needs to take … the necessary work to figure out what the best data sources are and what the impact of that kind of risk … For some of them, we can drive knowledge generation directly, like in the area of social risk. … For example, when it comes to the area of social risk, this is a place where CMS and our members have
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psnet.ahrq.gov/node/866343/psn-pdf
December 31, 2024 - Department disposition for patients during hypertensive
emergencies, and barriers to admitting high-risk … Syncope has different risk
stratifications depending on cardiac versus noncardiac etiologies, and ED … beds full at the time of admission, with administrative or clinical barriers to transferring a low-
risk … Hospitals should consider implementing policies
and procedures that direct patients with high-risk admitting