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www.ahrq.gov/sites/default/files/2024-07/domino-report.pdf
January 01, 2024 - Quality (AHRQ R21 HS19532).
1
ABSTRACT
Purpose: Physician-patient miscommunication with inadequate risk … Risk management resources were compared by estimated time and costs for processing patient
complaint … Informed
consent accounted for 41% of total risk management files. … the lists of risks to combine minor risks lacking numerical estimates of probability. … of total
risk management files) and 47 medical errors (24% of total risk management files).
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digital.ahrq.gov/sites/default/files/docs/technologies-underserved-populations-slides-02282023.pdf
February 28, 2023 - health outcomes
11
World Health Organization, https://www.who.int/
https://www.who.int/
Social Risk … relationship strain
COVID diagnosis/recovery
COVID vaccine
COVID physical distancing
COVID perceived risk … The Lancet Digital Health. 2020
46
Risk Factors Are Common
At birth Smoked during pregnancy 11.0% … Risks at action or
maintenance at 6
months
50.0 % (28.9) 42.7% (28.3) 1.16 <0.001
Risks at action … From the CDC:
Risk Factors Are Common
The Need
Components of Preconception Care
Who is Gabby?
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psnet.ahrq.gov/node/44257/psn-pdf
November 06, 2015 - This commentary describes a comprehensive analysis that identified risks related to ionizing radiation … psnet.ahrq.gov/issue/radiology-failure-mode-and-effect-analysis-what-it
https://psnet.ahrq.gov/issue/radiation-risks-diagnostic-imaging … https://psnet.ahrq.gov/issue/radiation-risks-diagnostic-imaging
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psnet.ahrq.gov/issue/cms-ruling-venous-thromboembolism-after-total-knee-or-hip-arthroplasty-weighing-risks-and
June 21, 2016 - The CMS ruling on venous thromboembolism after total knee or hip arthroplasty: weighing risks … The CMS ruling on venous thromboembolism after total knee or hip arthroplasty: weighing risks and benefits … The CMS ruling on venous thromboembolism after total knee or hip arthroplasty: weighing risks and benefits
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digital.ahrq.gov/research-method/time-series
January 01, 2023 - Samantha
Project Name
Understanding CancelRX: Impact on Clinical Workflows, Medication Safety Risks … Systems
Understanding CancelRX: Impact on Clinical Workflows, Medication Safety Risks … Understanding CancelRX: Impact on Clinical Workflows, Medication Safety Risks, and Patient Outcomes - … Samantha
Project Name
Understanding CancelRX: Impact on Clinical Workflows, Medication Safety Risks
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www.ahrq.gov/sites/default/files/2025-04/nemeth-report.pdf
January 01, 2025 - Key Words: human factors, risk assessment, safety
2. … Traditional risk assessment methods ill-suited to reveal risks in a complex sociotechnical system
such … For example, Probabilistic Risk Assessment (PRA) can be used to quantify
the likelihood of risk, but … the risk must be known. … Risk is the likelihood of exposure to hazard.
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psnet.ahrq.gov/node/35218/psn-pdf
August 07, 2018 - Building a Memory: Preventing Harm, Reducing Risks and
Improving Patient Safety. … https://psnet.ahrq.gov/issue/building-memory-preventing-harm-reducing-risks-and-improving-patient-safety … https://psnet.ahrq.gov/issue/building-memory-preventing-harm-reducing-risks-and-improving-patient-safety
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psnet.ahrq.gov/sites/default/files/2019-11/webmm_spotlight_suicide_risk_assessment.pdf
January 01, 2019 - a way that helps characterize acute risks, chronic risks, and
factors that are amenable to treatment … environmental (ligature) risks
– Provision of safe dining equipment
– Room sweeps
– Securing of personal … assessment for suicide based on a synthesis of multiple risk factors
– Reduce suicide risks by treating … treatment should match the severity and acuity of the
psychiatric disorders that underlie the suicide risks … assessment for suicide based on a synthesis of multiple risk factors,
– Reduce suicide risks by treating
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psnet.ahrq.gov/issue/language-barriers-and-patient-safety-risks-hospital-care-mixed-methods-study
May 18, 2016 - Study
Language barriers and patient safety risks in hospital care. … Language barriers and patient safety risks in hospital care. A mixed methods study. … Language barriers and patient safety risks in hospital care. A mixed methods study.
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psnet.ahrq.gov/issue/pediatric-safety-emergency-department-identifying-risks-and-preparing-care-child-and-family
July 08, 2009 - Commentary
Pediatric safety in the emergency department: identifying risks and preparing … Pediatric safety in the emergency department: identifying risks and preparing to care for child and family … Pediatric safety in the emergency department: identifying risks and preparing to care for child and family
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psnet.ahrq.gov/issue/ahrq-announces-interest-research-about-epidemiology-patient-safety-risks-and-harms-ambulatory
August 15, 2018 - Resource
AHRQ Announces Interest in Research About the Epidemiology of Patient Safety Risks … Citation Text:
AHRQ Announces Interest in Research About the Epidemiology of Patient Safety Risks and … Citation
Citation Text:
AHRQ Announces Interest in Research About the Epidemiology of Patient Safety Risks
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psnet.ahrq.gov/issue/identifying-patient-safety-risks-reporting-patient-complaints-grounded-theory-study-patients
December 20, 2017 - Study
From identifying patient safety risks to reporting patient complaints: a grounded … From identifying patient safety risks to reporting patient complaints: a grounded theory study on patients … From identifying patient safety risks to reporting patient complaints: a grounded theory study on patients
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psnet.ahrq.gov/issue/utilizing-information-technology-mitigate-handoff-risks-caused-resident-work-hour
March 17, 2010 - Commentary
Utilizing information technology to mitigate the handoff risks caused … Utilizing information technology to mitigate the handoff risks caused by resident work hour restrictions … Utilizing information technology to mitigate the handoff risks caused by resident work hour restrictions
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psnet.ahrq.gov/node/837908/psn-pdf
August 24, 2022 - /issue/implication-covid-19-pandemic-patient-safety-rapid-review
The COVID-19 pandemic created new risks … and exacerbated existing risks across all areas of health care
practice that challenge patient safety
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psnet.ahrq.gov/node/50625/psn-pdf
November 06, 2019 - pediatric-medication-safety-considerations-pharmacists-adult-hospital-setting
This Special Feature discusses risks … The authors identify risks and provide recommendations to ensure safe
care of children including optimizing
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psnet.ahrq.gov/issue/prone-score-algorithm-predicting-doctors-risks-formal-patient-complaints-using-routinely
September 07, 2011 - Study
The PRONE score: an algorithm for predicting doctors' risks of formal patient … The PRONE score: an algorithm for predicting doctors' risks of formal patient complaints using routinely … They developed a risk prediction model which predicted future complaints with reasonable accuracy. … Actions to reduce future litigation risk —such as directed education, referral to a regulatory agency … The PRONE score: an algorithm for predicting doctors' risks of formal patient complaints using routinely
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psnet.ahrq.gov/issue/are-temporary-staff-associated-more-severe-emergency-department-medication-errors
June 29, 2011 - prior studies have also demonstrated that high levels of temporary staff may pose patient safety risks … December 29, 2014
The harm susceptibility model: a method to prioritise risks identified … July 28, 2010
Identified safety risks with splitting and crushing oral medications.
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psnet.ahrq.gov/node/47943/psn-pdf
May 20, 2019 - https://psnet.ahrq.gov/issue/governing-safety-artificial-intelligence-healthcare
The unintended risks … This commentary suggests that strong guidance is necessary to reduce risks while
capitalizing on the … potential inherent in AI to enhance decision-making, diagnosis, and risk management.
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psnet.ahrq.gov/node/47904/psn-pdf
April 24, 2019 - psnet.ahrq.gov/issue/air-pressure-human-factors-are-key-safer-flight-environment
Air transport service combines risks … The author encourages efforts to
reduce risks through policy change, purchasing the latest safety equipment
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psnet.ahrq.gov/node/837675/psn-pdf
July 13, 2022 - Dashboard design to identify and balance competing risk
of multiple hospital-acquired conditions. … Dashboard design to identify and balance competing risk of
multiple hospital-acquired conditions. … https://psnet.ahrq.gov/issue/dashboard-design-identify-and-balance-competing-risk-multiple-hospital- … healthcare-acquired condition reduction and prevention target a single
condition, rather than the risks … discusses clinician
feedback on a proposed dashboard to enhance clinicians’ management combining the risks