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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module1/mod1-slides.html
March 01, 2017 - Slide 18: Understanding Risk and Human Behavior 1
Human Error:
Inadvertently completing the wrong … At-Risk Behavior:
Choosing to behave in a way that increases risk where risk is not recognized, or … Reckless Behavior:
Choosing to consciously disregard a substantial and unjustifiable risk.
1. … Slide 19: Managing Error and Risk 1
Human Error
At-Risk Behavior
Reckless Behavior … believed insignificant or justified
Manage through:
Removal of incentives for at-risk behaviors
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psnet.ahrq.gov/node/49483/psn-pdf
June 01, 2005 - procedures or for the use of high-risk drugs;
There was poor staff/trainee teamwork skills;
There … did not
ask for the indication, nor did it flag the order for pharmacist review despite the known risks … medications need to be treated similarly to high-risk procedures. … Medication reconciliation: a practical tool to reduce the risk of
medication errors. … processes/use of high-risk medications
No checks and balances for high-risk medications High
http:
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/-wqedxmwdpdE5BmzcBeTmn
December 01, 2009 - , there were
no sex-based differences in risks for self-harm, but there
were age-related differences … Age-Related Risks Associated With Second-Generation
Antidepressant Use
Two meta-analyses suggested an … to a lesser extent low-dose aspirin and other anticoagu-
lants, seemed to further increase bleeding risks … Risks
of suicide and poisoning among elderly patients prescribed selective serotonin
reuptake inhibitors … Uncertainty remains, and balance between risks and benefits should be considered for each
individual
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psnet.ahrq.gov/node/39441/psn-pdf
May 04, 2010 - Listen carefully: the risk of error in spoken medication
orders. … Listen carefully: the risk of error in spoken medication orders. … https://psnet.ahrq.gov/issue/listen-carefully-risk-error-spoken-medication-orders
This auditory perception … https://psnet.ahrq.gov/issue/listen-carefully-risk-error-spoken-medication-orders
https://psnet.ahrq.gov
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psnet.ahrq.gov/node/37070/psn-pdf
April 21, 2011 - Excessive work hours of physicians in training in El
Salvador: putting patients at risk. … Excessive work hours of physicians in training in El Salvador: putting patients at risk. … https://psnet.ahrq.gov/issue/excessive-work-hours-physicians-training-el-salvador-putting-patients-risk … https://psnet.ahrq.gov/issue/excessive-work-hours-physicians-training-el-salvador-putting-patients-risk
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psnet.ahrq.gov/node/42799/psn-pdf
December 04, 2013 - All can be lost: the risk of putting our knowledge in the
hands of machines. … https://psnet.ahrq.gov/issue/all-can-be-lost-risk-putting-our-knowledge-hands-machines
Increasingly, … computerized systems are performing more complex tasks in high-risk industries like aviation
and medical … https://psnet.ahrq.gov/issue/all-can-be-lost-risk-putting-our-knowledge-hands-machines
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www.uspreventiveservicestaskforce.org/uspstf/recommendation/gonorrhea-screening-including-ocular-prophylaxis-newborns-1996
January 01, 1996 - Asymptomatic women
Routine screening for gonorrhea is recommended for asymptomatic women at high risk … B
High-risk men
There is insufficient evidence to recommend for or against screening high-risk … factors was 2.5%, compared to 0.2% for women with no risk factors. … Actual risk, however, will depend on the local epidemiology of disease. … Maternal gonococcal infection as a preventable risk factor for low birth weight.
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psnet.ahrq.gov/issue/description-medical-malpractice-claims-involving-advanced-practice-providers
August 19, 2020 - J Healthc Risk Manag. 2021;40(3):8-16. doi:10.1002/jhrm.21412. … J Healthc Risk Manag . 2021; 40 (3) :8-16 .
View more articles from the same authors. … J Healthc Risk Manag. 2021;40(3):8-16. doi:10.1002/jhrm.21412. … May 11, 2022
New graduate registered nurses: Risk mitigation strategies to ensure safety … August 3, 2022
Gender bias in risk management reports involving physicians in training
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psnet.ahrq.gov/issue/retained-foreign-bodies-after-surgery
November 23, 2011 - The authors performed a case control analysis of medical records for a 10-year period to identify risk … September 23, 2020
Operating room traffic as a modifiable risk factor for surgical site … risk stratification system. … October 17, 2012
Risk factors associated with incorrect surgical counts. … September 29, 2011
Risk factors for retained instruments and sponges after surgery.
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psnet.ahrq.gov/issue/patient-safety-public-health
July 19, 2023 - J Healthc Risk Manag. 2014;34(1):6-12. doi:10.1002/jhrm.21145. … J Healthc Risk Manag . 2014; 34 (1) :6-12 .
View more articles from the same authors. … J Healthc Risk Manag. 2014;34(1):6-12. doi:10.1002/jhrm.21145. … June 26, 2019
Burnout and sources of stress among health care risk managers and patient … November 18, 2016
View More
See More About The Topic
Risk Managers
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psnet.ahrq.gov/issue/risk-care-plans-way-reduce-readmissions-and-adverse-events
October 27, 2010 - Commentary
At risk care plans: a way to reduce readmissions and adverse events. … At Risk Care Plans: a way to reduce readmissions and adverse events. … describes one hospital's effort to decrease readmissions and adverse events involving inpatients at risk … At Risk Care Plans: a way to reduce readmissions and adverse events. … 14, 2023
Use of unsolicited patient observations to identify surgeons with increased risk
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www.ahrq.gov/research/findings/final-reports/ssi/ssiapvtables.html
April 01, 2018 - Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection
Appendix … Designing and Testing Methods to Stratify Risk of Surgical Site Infections
Chapter 4. … Initial Risk Factors
Appendix J. Additional Risk Factors
Appendix K. … Final Risk Factors
Appendix L. … Surgeons' Acceptance of Surgical Site Infection Risk Adjustment Models
Appendix T.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b3b_combo_resultspresentation.pdf
June 02, 2025 - Currently the
ICD-10 software does not
calculate expected, risk-
adjusted, or smoothed rates,
but … and Smoothed Rates of Pressure Ulcers (PSI 03)
Risk-Adjusted Rate
Risk-Adjusted (Lower Confidence … Rates of Pressure Ulcers (PSI 03) to National Average Rates
Risk-Adjusted Rate
Risk-Adjusted (Lower … Currently the ICD-10 software does not calculate expected, risk-adjusted, or smoothed rates, but will … Comparing Observed Performance to Expected Performance Over Time
Comparing Risk-Adjusted and Smoothed
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes8.html
August 01, 2022 - and creates a culture of inquiry and dialogue in which people feel safe to share openly and to take risks … It must include engagement of key stakeholders, such as senior leaders, risk managers, staff, patients
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psnet.ahrq.gov/primer/computerized-provider-order-entry
March 15, 2025 - electronic health systems (EHR) has benefited clinicians and patients, but it also vividly illustrates the risks … July 8, 2020
View More
Related WebM&M
The Lost Start Date: an Unknown Risk
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cds.ahrq.gov/sites/default/files/workgroups/221/feb-2017-cholesterol-wg-notes.docx
January 01, 2017 - 1:30 – 3:30 PM ET
AGENDA
· Welcome
· Discuss Remaining Repository Questions
· Clarify 10-Year Risk … Clarify 10-Year Risk Assessment Details
Evaluation of the patient record to appropriately identify risk … appropriate representation and constraints for certain data elements used to calculate the 10-year risk … 6 years for the LDL-c laboratory result, citing the 2013 ACC/AHA guideline recommendation to assess risk … Currently, providers may have to navigate to a different screen/application to obtain the risk score,
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www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan/vision-screening-children-ages-6-months-5-years
July 24, 2025 - Framework
a Amblyopia risk … Does screening for amblyopia, its risk factors, and refractive error in children ages 6 months to 5 years … What is the accuracy and reliability of screening tests for amblyopia, its risk factors, and refractive … What are the harms of screening for amblyopia, its risk factors, and refractive error in children ages … What are the harms of treatment of amblyopia, its risk factors, and refractive error in children ages
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/guide/apc.html
October 01, 2017 - Using Pressure Ulcer Risk Assessment Tools in Care Planning
Presented by Elizabeth Ayello, Ph.D., … This webinar discusses pressure injury risk factor assessment, tools, and care planning. … Risk Factors for Pressure Ulcers: Going Beyond Validated Instruments
Presented by Elizabeth Ayello … This webinar reviews the importance of addressing the subscale risk factors in a risk assessment tool … This webinar examines the undernutrition-malnutrition continuum and the impact of inflammation on risk
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/tmpufJqkzbptG4uBtSGnam
September 01, 2022 - Screen for syphilis in persons at increased risk … • Adolescents and adults who have ever been sexually active and are at increased risk for syphilis infection … The USPSTF continues
to recommend screening for syphilis in nonpregnant persons who are at increased risk … Assess risk:
• Risk of syphilis is higher in men who have sex with men; persons with HIV infection … should be aware of how common syphilis infection is in their community and assess
patient’s individual risk
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/methods-guidance-reporting-bias_methods.pdf
November 01, 2013 - Agency found that while published data indicated that benefits of the study drugs outweighed
their risks … , that the inclusion of unpublished data suggested that risks outweighed benefits for all
but one of … additional data (11 studies; 996 patients)
18
changed results from statistically significant (RR [relative … for reporting bias for this outcome (“ORB risk–” or “ARB risk–”). … the results were reported, then
the study is at risk of reporting bias for that outcome (“ORB risk