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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.296_slideshow.ppt
April 01, 2013 - 36/2_suppl.toc
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PN: a High-Alert “Medication”
High-alert medications, by definition, involve risk … used in error
PN is characterized as a high-alert medication
Safeguards are required to minimize risk … of errors with PN
Errors in PN-use process may be more dangerous than risks with PN ingredients and … Results of ISMP survey on high-alert medications: differences between nursing, pharmacy, and risk/quality … Available at http://intl-pen.sagepub.com/content/30/3/259.full
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Transitions in Care and PN
High risk
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psnet.ahrq.gov/node/49504/psn-pdf
March 01, 2006 - A recent study (1) found that men have a two times greater risk of
hematoma than women in cosmetic procedures … Safe and sound practice requires such identification of all
potential high-risk areas, such as blood … larger
diameter–tipped cannulae have, for the most part, faded out of use primarily because of the risks … A related study (10) of liposuction of
the neck and jowls also found an extremely low risk of voluntarily … Evidence-based techniques should be employed in outpatient plastic surgery to reduce the risk of
complications
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/indwelling-urinary-catheter-use/catheter-insertion/unlicensed-staff/unlicensed-catheter-slides.html
March 01, 2017 - Engineering out the risk of infection with urinary catheters . … Engineering out the Risk for Infection with Urinary Catheters . … Nursing interventions to reduce the risk of catheter‐associated urinary tract infection: part 2: staff … Nursing interventions to reduce the risk of catheter‐associated urinary tract infection: part 2: staff … Engineering out the Risk for Infection with Urinary Catheters .
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0129table9.pdf
January 01, 2008 - Table 9 – Analysis of Disparities in Readmission Risk Based on Race/Ethnicity
2005-2009 AHRQ Revisit … [1.20 – 1.29]
Other 1.03 [0.98 – 1.07]
Table 10 – Analysis of Disparities in Readmission Risk … 1.26]
Native American 1.09 [0.99 - 1.20]
Table 11 – Analysis of Disparities in Readmission Risk
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effectivehealthcare.ahrq.gov/sites/default/files/cer-240-acute-pain-evidence-summary.pdf
December 01, 2020 - • Opioids are probably associated with increased risk of short-term adverse events
versus nonopioid … Evidence did not suggest an
increased risk of serious harms for any intervention, though studies were … Serious adverse events were uncommon, but studies were not designed to
assess risk of overdose, opioid … Being prescribed
3
opioids might be associated with increased risk of long-term use versus … Legislation mandating the use of prescription drug
monitoring data and an opioid risk assessment tool
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psnet.ahrq.gov/node/49580/psn-pdf
March 21, 2009 - The Joint Commission recognizes that patients are most at risk for medication errors when
transitioning … Generic Drug Name Concerns
Indomethacin High risk of developing central nervous system adverse events … Diphenhydramine, chlorpheniramine,
hydroxyzine, other anticholinergic
antihistamines
High risk of … Phenobarbital, other barbiturates
Highly addictive, high risk of adverse events including sedation, … risk of falls.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/b2a_pdi_ratesgenbysas.pdf
March 01, 2016 - Note: The current version of the AHRQ QI software does not have risk-adjustment capabilities
when using … However, this tool includes information about risk adjustment that will
be relevant when looking at … Identify pediatric populations at risk.
3. Calculate observed (raw) indicator rates.
4. … Risk adjust the indicator rates (where applicable).
5. … These observed rates are stratified by risk group
categories that are specific to each indicator.
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psnet.ahrq.gov/primer/detection-safety-hazards
March 30, 2022 - methods Failure mode and effect analysis (FMEA) is a common approach to prospectively determine error risk … FMEA (or similar techniques) has been used in other high-risk industries for prospective safety analysis … Human factors engineers often lead safety efforts in other high-risk industries, and recent commentaries … Current context The Joint Commission currently requires all hospitals to conduct one prospective risk … August 1, 2023
Combined proactive risk assessment: unifying proactive and reactive risk assessment
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digital.ahrq.gov/ahrq-funded-projects/self-management-reminders-technology-smart-appraisal-integrated-personal-health
January 01, 2023 - disease is the leading cause of mortality in the U.S. and as the population ages, the disease and its risk … Many of these risk factors, including elevated lipids, hypertension, obesity, and diabetes, are responsive … Patients who had either cardiovascular disease or two risk factors for the development of cardiovascular … Secondary outcomes included calculations of 10-year cardiovascular risk, changes in cardiovascular risk … Overall, users of the active PHR did not reduce their cardiovascular risk versus the control group at
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digital.ahrq.gov/ahrq-funded-projects/multi-site-trial-test-benefits-adding-personalized-risk-calculator-online/citation/integrating
January 01, 2023 - Integrating personalized risk scores in decision making about left ventricular assist device (LVAD) therapy … Integrating personalized risk scores in decision making about left ventricular assist device (LVAD) therapy … Blumenthal-Barby, Jennifer
Project Name
A Multi-Site Trial to Test Benefits of Adding a Personalized Risk
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psnet.ahrq.gov/node/46149/psn-pdf
June 28, 2017 - clinical-outcomes-associated-medication-regimen-complexity-older-people-
systematic-review
Older adults are at increased risk … for adverse drug events, especially those who take high-risk medications. … emergency-hospitalizations-adverse-drug-events-older-americans
https://psnet.ahrq.gov/issue/reducing-risk-adverse-drug-events-older-adults
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-131-section-7-a-table-10-11-12.pdf
January 01, 2008 - Table 10 – Analysis of Disparities in Readmission Risk … Hispanic 1.33 [1.20 – 1.48]
Other 1.08 [0.95 – 1.22]
Table 11 – Analysis of Disparities in Readmission Risk … 1.06 - 2.07]
Native American 1.26 [1.06 - 1.50]
Table 12 – Analysis of Disparities in Readmission Risk
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/webinars.html
October 01, 2017 - Using Pressure Ulcer Risk Assessment Tools in Care Planning (44 min) ( PDF of the Slides , 2.33 MB). … 73 min)
Putting the Nutrition Guidelines into Practice for Pressure Injury Prevention (62 min)
Risk … Going Beyond Validated Instruments (60 min)
Sustainment (61 min)
Video
Assessing Patient Risk
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psnet.ahrq.gov/node/846767/psn-pdf
March 29, 2023 - Electronic health records (EHRs) are key for the collection of patient care data to inform overarching risk … quality-and-safety-learning-past-and-reimagining-future
https://psnet.ahrq.gov/issue/opportunities-mine-ehrs-malpractice-risk-management-and-patient-safety … https://psnet.ahrq.gov/issue/opportunities-mine-ehrs-malpractice-risk-management-and-patient-safety
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psnet.ahrq.gov/node/43606/psn-pdf
October 15, 2014 - https://psnet.ahrq.gov/issue/opioids-chronic-noncancer-pain-position-paper-american-academy-neurology
Risk … includes recommendations for neurologists to reduce the
likelihood of adverse events involving these high-risk … https://psnet.ahrq.gov/issue/safe-use-opioids-hospitals
https://psnet.ahrq.gov/issue/identifying-high-risk-medication-systematic-literature-review
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psnet.ahrq.gov/node/50936/psn-pdf
February 26, 2020 - assessing the effectiveness of bedside “sitters” for agitated
patients who appear to be at high fall risk … In general, the researchers found very-low-certainty evidence
that sitters reduce fall risk in acute … moderate-certainty that alternatives (e.g., video
monitoring) can reduce sitter use without increasing fall risk
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psnet.ahrq.gov/node/48149/psn-pdf
July 31, 2019 - This book
draws on the experience of high-risk industries to provide practices and tools that translate … psnet.ahrq.gov/issue/can-we-import-improvements-industry-healthcare
https://psnet.ahrq.gov/issue/learning-high-risk-industries-may-not-be-straightforward-qualitative-study-hierarchy-risk
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www.uspreventiveservicestaskforce.org/uspstf/document/final-evidence-review55/genital-herpes-screening-2005
March 15, 2005 - Can Risk Factors Identify Groups at Higher Risk for HSV Infection? … The relative risk for subclinical viral shedding was 0.09 (95% CI, 0.03-0.35) for the women who received … ; HSV, herpes simplex virus; PCR, polymerase chain reaction; RCT, randomized controlled trials; RR, relative … risk. … Can risk factors identify groups at higher risk for HSV infection?
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/heart-failure-transition-care_research-protocol.pdf
June 10, 2013 - years of age.11
Coronary disease and uncontrolled hypertension are the highest population-attributable risks … Assessment of Methodological Risk of Bias of Individual Studies
To assess the risk of bias (i.e., … A study with moderate risk of bias is susceptible to some risk of bias but probably not
enough to invalidate … A study assessed as having high risk of bias has significant risk
of bias (e.g., stemming from serious … Two independent reviewers will assess risk of bias for each study.
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/care-adults-down-syndrome-protocol.pdf
July 09, 2024 - , and race.15-17 With
the increase in life expectancy, knowledge of the physical and mental health risks … Assessment of Methodological Risk of Bias of Individual Studies
Risk of bias of included KQ studies … We will calculate
risk ratios (RR) and absolute risk differences (RD) with the corresponding 95 percent … difference
ROB Risk of bias
ROBINS-I Risk OF Bias In Non-Randomized Studies-of Interventions … or risk?