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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apd.html
August 01, 2022 - CULTURE
Have leaders established methods to identify risks and provide employees opportunities … FUTURE RISKS
Are there other areas in the organization where this could happen?
… FUTURE RISKS
Are there opportunities to improve trainings, competencies and orientation sessions
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psnet.ahrq.gov/issue/uncovering-risks-anticancer-therapy-through-incident-report-analysis-using-newly-developed
January 29, 2018 - Study
Uncovering the risks of anticancer therapy through incident report analysis … Uncovering the risks of anticancer therapy through incident report analysis using a newly developed medical … Oncology is a high-risk care environment involving complex medication administration. … The researchers identified nine intermediate- and high-risk scenarios carrying the greatest risk to patient … Uncovering the risks of anticancer therapy through incident report analysis using a newly developed medical
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psnet.ahrq.gov/node/867036/psn-pdf
January 01, 2025 - Artificial intelligence-powered chatbots in search
engines: a cross-sectional study on the quality and risks … Artificial intelligence-powered chatbots in search engines: a
cross-sectional study on the quality and risks
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psnet.ahrq.gov/issue/risks-and-medication-errors-analysis-evaluate-impact-chemotherapy-compounding-workflow
January 27, 2019 - Study
Risks and medication errors analysis to evaluate the impact of a chemotherapy … Risks and medication errors analysis to evaluate the impact of a chemotherapy compounding workflow management … Risks and medication errors analysis to evaluate the impact of a chemotherapy compounding workflow management … September 1, 2016
Inappropriate hospital admission as a risk factor for the subsequent … June 15, 2012
Use of a prospective risk analysis method to improve the safety of the
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psnet.ahrq.gov/node/843413/psn-pdf
February 01, 2023 - toward-translation-systems-thinking-methods-patient-safety-practice-
assessing-validity-net
Organizations are encouraged to proactively identify patient safety risks … This article
describes validity testing of systems-thinking risk assessment (Net-HARMS) to identify … risks associated
with patient medication administration and an accident analysis method (AcciMap) to
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www.ahrq.gov/hai/cusp/modules/engage/alt-text.html
April 01, 2013 - Joins frontline staff and middle manager for rounds and a 1-hour monthly meeting
Considers patient risks … and involves frontline personnel in creating ways to mitigate those risks
Reviews unit data with team … 13
Collaborates To Develop and Implement a Plan Addressing Safety Issues
Considers patient risks … identified in the Staff Safety Assessment with team members
Involves frontline providers to help reduce risks
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psnet.ahrq.gov/issue/what-are-safety-risks-patients-undergoing-treatment-multiple-specialties-retrospective
March 18, 2013 - Study
What are the safety risks for patients undergoing treatment by multiple specialties … What are the safety risks for patients undergoing treatment by multiple specialties: a retrospective … This study found that the risk of errors increases with the number of specialties treating a patient. … What are the safety risks for patients undergoing treatment by multiple specialties: a retrospective … February 8, 2012
Integration of prospective and retrospective methods for risk analysis
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psnet.ahrq.gov/node/866525/psn-pdf
August 14, 2024 - Clinicians felt challenged when balancing risks and benefits of
further prescribing. … stakeholder-perceptions-and-attitudes-towards-problematic-polypharmacy-and-prescribing
https://psnet.ahrq.gov/issue/risks-prescribing-cascade
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effectivehealthcare.ahrq.gov/sites/default/files/communicating_risk_media_wilkes.ppt
April 01, 2006 - , small differences between risks, and uncertainty around risks
Public Expectations
Public believes … million cases of breast cancer.
raloxifene is already used to prevent bone loss after menopause
NCI used relative … risk reductions in their promotion rather than absolute risk reductions
At the press release and conference … Why are risks minimized? … new possibilities
Tools to help patients better understand the health care system and risk
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www.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-slides.html
February 01, 2017 - How will you reduce the risk of it happening again?
How will you know the risk was reduced? … Slide 28: How Will You Know Risks Were Reduced? … Do staff believe risks were reduced?
Make data-driven metrics the goal whenever possible. … Slide 29: How Will You Know Risks Were Reduced?
Identify how you will measure success. … Slide 30: How Will You Know Risks Were Reduced?
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psnet.ahrq.gov/node/47584/psn-pdf
February 20, 2019 - patient-involvement-evaluation-safety-oral-antineoplastic-treatment-failure-
mode-and-effects
This study employed failure mode and effect analysis to detect risks … included both provider and patient perspectives and found that the two groups identified
distinct risks
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psnet.ahrq.gov/node/853244/psn-pdf
September 06, 2023 - This article highlights five patient safety risks
during pediatric perioperative blood management (failure … The authors discuss potential solutions to address these safety risks.
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psnet.ahrq.gov/issue/identifying-risks-and-opportunities-outpatient-surgical-patient-safety-qualitative-analysis
November 10, 2010 - Study
Identifying risks and opportunities in outpatient surgical patient safety: … Identifying Risks and Opportunities in Outpatient Surgical Patient Safety: A Qualitative Analysis of … This qualitative study asked surgical staff about risk factors for adverse events in outpatient surgery … Identifying Risks and Opportunities in Outpatient Surgical Patient Safety: A Qualitative Analysis of
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www.ahrq.gov/hai/cusp/toolkit/content-calls/framework-slides/slides.html
October 01, 2014 - Ensure unit team has resources to reduce risks. … What could you do to reduce risk?
How do you know risk was reduced? … Do staff believe risks have been reduced?
Return to Contents
Slide 31. … What are potential risks during the day; how can we reduce these risks? … Safety survey to identify at-risk departments.
Mandatory science of safety training.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-slides.pptx
January 01, 2017 - First-Order
Problem Solving
Second-Order
Problem Solving
Recovers for one patient, but does not reduce risks … for future patients
Example: You get the supply from another area or you manage without it
Reduces risks … How will you reduce the risk of it happening again? … How Will You Reduce Risk Reoccurring? … Do staff believe risks were reduced?
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psnet.ahrq.gov/node/49868/psn-pdf
July 02, 2019 - Because of the drug's risks for adverse effects, clozapine must be
prescribed and dispensed in accordance … The purpose of REMS
is to reduce the occurrence or severity of serious known risks. … Rather, it is focused on preventing, monitoring, and/or managing very specific and serious risks—to … , known
medication safety risks. … Approved Risk Evaluation and Mitigation Strategies (REMS).
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www.ahrq.gov/research/findings/final-reports/stpra/stpra4.html
April 01, 2018 - Study Strengths and Limitations
ST-PRA is a valuable and important tool for assessing the risks associated … unique combinations of risks that contribute to the adverse outcome. … Return to Contents
Next Steps
The use of ST-PRA as a modeling tool to identify risks in the ASC … years, there have been a variety of methods and tools designed to improve our understanding of the many risks … and easier to use by health care providers as they attempt to improve system design and reduce the risks
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psnet.ahrq.gov/node/837663/psn-pdf
July 13, 2022 - Long-term risk of overdose or mental health crisis after
opioid dose tapering. … Long-term risk of overdose or mental health crisis after opioid
dose tapering. … This study assessed the long-term risks of overdose and mental health crisis
as a result of dose tapering … Consistent with earlier research on short-term risks, results indicate that opioid
tapering is associated … with increased risk of adverse events up to 24 months after initiation of tapering.
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psnet.ahrq.gov/issue/laboratory-test-ordering-and-results-management-systems-qualitative-study-safety-risks
March 16, 2016 - Laboratory test ordering and results management systems: a qualitative study of safety risks … Laboratory test ordering and results management systems: a qualitative study of safety risks identified … Laboratory test ordering and results management systems: a qualitative study of safety risks identified
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psnet.ahrq.gov/issue/harm-susceptibility-model-method-prioritise-risks-identified-patient-safety-reporting-systems
December 29, 2014 - Study
The harm susceptibility model: a method to prioritise risks identified in patient … The harm susceptibility model: a method to prioritise risks identified in patient safety reporting systems … The harm susceptibility model: a method to prioritise risks identified in patient safety reporting systems