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hcup-us.ahrq.gov/reports/statbriefs/sb237-Patient-Safety-Adverse-Events-2011-2014.pdf
January 01, 2014 - ■ The hospital risk-adjusted rates
per 1,000 discharges of all 13
PSIs decreased in 34 States
from … PSIs are reported as the number of adverse patient safety events per 1,000
discharges at risk. … PSIs are reported as the number of adverse patient safety events per 1,000 discharges at risk. … PSIs are reported as the number of adverse patient safety events per 1,000 discharges at risk. … All rates were risk adjusted using the PSI software.
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digital.ahrq.gov/sites/default/files/docs/page/ahrq-dhr-2022-year-in-review-at-a-glance.pdf
January 01, 2022 - Closing the Communication Gap
Between Prescribers and Pharmacists to
Decrease Medication Safety Risks … California, Los
Angeles
Emerging
Continuous Predictive Analytics
Monitoring to Improve Care for At-Risk … digital.ahrq.gov/program-overview/research-stories/continuous-predictive-analytics-monitoring-improve-care-risk … digital.ahrq.gov/program-overview/research-stories/continuous-predictive-analytics-monitoring-improve-care-risk … Mayo Clinic
Rochester
Emerging
Decision Precision+: Increasing Lung
Cancer Screening for At-Risk
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psnet.ahrq.gov/node/46856/psn-pdf
June 20, 2018 - visual-acuity-literacy-and-unintentional-misuse-nonprescription-medications
Prior research has shown that patients with limited health literacy are at increased risk … In this study, researchers examined the risk of
nonprescription acetaminophen misuse among 500 English-speaking … Both reduced
visual acuity and lower health literacy were independent risk factors for dosing errors … psnet.ahrq.gov/issue/literacy-and-misunderstanding-prescription-drug-labels
https://psnet.ahrq.gov/issue/risk-unintentional-overdose-non-prescription-acetaminophen-products
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/renal-function_disposition-comments.pdf
August 11, 2014 - Does this portend increased
cardiovascular risk? … This is the primary
use of troponin for risk stratification. … of the systematic review) is the lack
of therapeutics that can be engaged to reduce cardiovascular risks … evaluating a biomarker in how much it
discriminates and re-classifies individuals
into higher and lower risks … Elevation
of this biomarker is associated with an
increased risk.
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psnet.ahrq.gov/issue/changes-early-high-risk-opioid-prescribing-practices-after-policy-interventions-washington
November 03, 2021 - Study
Changes in early high-risk opioid prescribing practices after policy interventions … Changes in early high‐risk opioid prescribing practices after policy interventions in Washington State … different times (including dosing guidelines and prescription drug monitoring ) and changes in high-risk … There was a general shift towards more infrequent and lower-risk prescribing, and each policy intervention … Changes in early high‐risk opioid prescribing practices after policy interventions in Washington State
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psnet.ahrq.gov/issue/child-age-and-risk-medication-error-multisite-childrens-hospital-study
August 28, 2024 - Study
Child age and risk of medication error: a multisite children's hospital study … Child age and risk of medication error: a multisite children's hospital study. … Pediatric patients are at increased risk of medication errors compared to adults, and this study sought … to determine if a child's age is associated with risk of medication error. … Child age and risk of medication error: a multisite children's hospital study.
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psnet.ahrq.gov/issue/risk-controls-identified-action-plans-following-serious-incident-investigations-secondary
April 22, 2017 - Study
Risk controls identified in action plans following serious incident investigations … Risk controls identified in action plans following serious incident investigations in secondary care: … of contributory factors were not addressed by the action plans and that three-quarters of proposed risk … Risk controls identified in action plans following serious incident investigations in secondary care: … study of the hierarchy of risk controls approach in healthcare.
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psnet.ahrq.gov/issue/safe-opioid-prescribing-prognostic-machine-learning-approach-predicting-30-day-risk-after
July 22, 2020 - Safe opioid prescribing: a prognostic machine learning approach to predicting 30-day risk … Safe opioid prescribing: a prognostic machine learning approach to predicting 30-day risk after an opioid … Opioids are high-risk medications and a significant source of patient harm . … prescription from 2017-2018, the authors developed machine learning models to estimate the 30-day risk … Safe opioid prescribing: a prognostic machine learning approach to predicting 30-day risk after an opioid
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psnet.ahrq.gov/issue/risk-assessment-acute-stroke-diagnostic-process-using-failure-modes-effects-and-criticality
July 21, 2021 - Study
Risk assessment of the acute stroke diagnostic process using failure modes, … Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality … A missed or delayed diagnosis of stroke places patients at risk of permanent disability or death. … Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality … November 1, 2017
Redesigning surgical decision making for high-risk patients.
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psnet.ahrq.gov/issue/vital-signs-are-still-vital-instability-discharge-and-risk-post-discharge-adverse-outcomes
September 23, 2020 - Study
Vital signs are still vital: instability on discharge and the risk of post-discharge … Vital Signs Are Still Vital: Instability on Discharge and the Risk of Post-Discharge Adverse Outcomes … Identifying patients at high risk of readmission following hospital discharge is a patient safety priority … Patients with multiple abnormal vital signs were at highest risk for readmission . … Vital Signs Are Still Vital: Instability on Discharge and the Risk of Post-Discharge Adverse Outcomes
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/potential-problem-analysis
January 01, 2023 - ESTIMATE THE RISK of each problem by assigning it a high, medium, or low rating for both its likelihood … Record it in the fifth column and rate the residual risk, the likelihood, and severity of the cause with … DEVELOP A CONTINGENCY PLAN to minimize the consequences of causes with unacceptable residual risk, should … Advantages
Addresses causes, evaluates risk, and keeps preventive actions and contingency plans separate
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/3khZ9a2mY7eYPVhNY5ZdkC
Grade: B
Risk Assessment
Risk factors for abnormal glucose metabolism include overweight and … Abnormal glucose metabolism is also frequently associated with other cardiovascular risk factors, such … USPSTF
Recommendations
The USPSTF recommends screening and appropriate interventions for modifiable risk
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psnet.ahrq.gov/issue/investigation-role-clinical-pharmacy-services-helping-identify-and-reduce-high-risk
September 29, 2021 - Investigation into the Role of Clinical Pharmacy Services in Helping to Identify and Reduce High-risk … Investigation into the Role of Clinical Pharmacy Services in Helping to Identify and Reduce High-risk … Investigation into the Role of Clinical Pharmacy Services in Helping to Identify and Reduce High-risk … September 29, 2021
Investigation into Management of Venous Thromboembolism Risk in Patients … September 7, 2022
Investigation into Management of Venous Thromboembolism Risk in Patients
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cds.ahrq.gov/sites/default/files/cds/artifact/476/EnhancementofCDSArtifact%20BasedonPilotImplementation10012018.pdf
December 01, 2018 - patient and the provider regarding the effectiveness of
existing treatments, and the benefits and risks … the need to evaluate for risk
factors prior to initiating opioid
therapy. … Risk factors outlined in the
guideline include: depression,
anxiety, substance use disorder,
suicide … , active or
recurring status, onset date, asserted date, abatement date)
o Encounter Risk Diagnosis … LOINC
representatives are currently expanding representation of pain and opioid risk assessments as
-
digital.ahrq.gov/sites/default/files/docs/citation/cds-artifact-enhancement.pdf
December 01, 2018 - patient and the provider regarding the effectiveness of
existing treatments, and the benefits and risks … the need to evaluate for risk
factors prior to initiating opioid
therapy. … Risk factors outlined in the
guideline include: depression,
anxiety, substance use disorder,
suicide … , active or
recurring status, onset date, asserted date, abatement date)
o Encounter Risk Diagnosis … LOINC
representatives are currently expanding representation of pain and opioid risk assessments as
-
psnet.ahrq.gov/node/36033/psn-pdf
June 21, 2006 - Infants at risk: when nurse fatigue jeopardizes quality
care. … https://psnet.ahrq.gov/issue/infants-risk-when-nurse-fatigue-jeopardizes-quality-care
The authors discuss … https://psnet.ahrq.gov/issue/infants-risk-when-nurse-fatigue-jeopardizes-quality-care
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www.uspreventiveservicestaskforce.org/uspstf/document/evidence-summary14/lung-cancer-screening
March 09, 2021 - For KQ2 (on risk prediction), externally validated models aimed at identifying persons at increased risk … Does the use of risk prediction models for identifying adults at higher risk of lung cancer mortality … Second, the KQ on risk prediction models (KQ2) was limited to how well risk prediction models perform … on risk threshold selected)
Good: 6 Fair: 3
No trials have compared use of a risk prediction model … with risk factor–based criteria; evidence base is limited by lack of an established risk threshold;
-
psnet.ahrq.gov/node/49687/psn-pdf
August 21, 2013 - https://psnet.ahrq.gov/web-mm/emergency-error
Case Objectives
State that emergency surgery is high risk … Appreciate that emergency laparotomy is a particularly high-risk procedure with a high likelihood of … Understand that clinical experience and seniority may reduce the risk of errors associated with
emergency … Describe how variability in processes of care can increase the risk to patients undergoing emergency … Risk and prediction of risk using multiple logistic regression analysis.
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psnet.ahrq.gov/node/37915/psn-pdf
January 27, 2009 - Barcode technology flaws put some patients at risk.
January 27, 2009
Preidt R. ABC News. … https://psnet.ahrq.gov/issue/barcode-technology-flaws-put-some-patients-risk
This article discusses … https://psnet.ahrq.gov/issue/barcode-technology-flaws-put-some-patients-risk
https://psnet.ahrq.gov/issue
-
psnet.ahrq.gov/node/35727/psn-pdf
February 22, 2006 - Risk of medication errors at hospital discharge and
barriers to problem resolution. … https://psnet.ahrq.gov/issue/risk-medication-errors-hospital-discharge-and-barriers-problem-resolution … https://psnet.ahrq.gov/issue/risk-medication-errors-hospital-discharge-and-barriers-problem-resolution