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psnet.ahrq.gov/issue/reducing-accidental-extubation-neonates
September 09, 2011 - Healthcare system-wide implementation of opioid-safety guideline recommendations: the case of urine drug screening … and opioid-patient suicide- and overdose-related events in the Veterans Health Administration. … April 5, 2017
Economic value of pharmacist-led medication reconciliation for reducing … June 5, 2018
Don't underestimate the impact of change on risk potential. … Reducing catheter-associated bloodstream infections in the pediatric intensive care unit: business case for
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psnet.ahrq.gov/issue/piece-my-mind-trials-and-tribulations
October 19, 2022 - May 11, 2022
Effect of an emergency department process improvement package on suicide … May 31, 2023
International evaluation of an AI system for breast cancer screening. … March 2, 2022
2014 Annual Benchmarking Report: Malpractice Risks in the Diagnostic Process … Coalition: making the case for full disclosure. … January 21, 2015
Sued for misdiagnosis? It could happen to you.
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psnet.ahrq.gov/periodic-issue/periodic-issue-402
August 30, 2023 - Study
The impact of primary care providers' bias on depression screening for lesbian … Regular depression screening is recommended for all adults. … depression screening. … Suicide at the John Cochran Division of the VA St. … This report analyzed a patient suicide at an emergency department and determined factors in the delay
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psnet.ahrq.gov/issue/universal-protection-operationalizing-infection-prevention-guidance-covid-19-era
August 18, 2021 - The framework was implemented in one large health system with high levels of compliance, particularly for … Citation
Related Resources From the Same Author(s)
Implementing universal suicide … risk screening in a pediatric hospital. … July 13, 2022
Bracing for the storm: one health care system's planning for the COVID- … November 18, 2020
Bracing for the storm: one health care system's planning for the COVID
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psnet.ahrq.gov/periodic-issue/periodic-issue-344
May 16, 2022 - preexisting maternal and neonatal morbidities, which may increase risk for cesarean delivery. … preexisting maternal and neonatal morbidities, which may increase risk for cesarean delivery. … High POS was also associated with lower odds of screening positive for burnout, mental health systems … known about suicide in outpatient settings. … Study
Surgery is in itself a risk factor for the patient.
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psnet.ahrq.gov/issue/ambulance-diversion-associated-reduced-access-cardiac-technology-and-increased-one-year
October 27, 2016 - Overcrowding in emergency departments is a recognized safety hazard for patients. … ambulance diversion had decreased access to life-saving therapies and had an increased one-year mortality risk … June 29, 2011
Experiences of physicians investigated for professionalism concerns: a … December 19, 2017
Longitudinal trends in U.S. drug shortages for medications used in … June 7, 2016
A prospective study of suicide screening tools and their association with
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psnet.ahrq.gov/issue/when-disasters-strike-emergency-department-case-series-and-narrative-review
September 30, 2020 - Healthcare system-wide implementation of opioid-safety guideline recommendations: the case of urine drug screening … and opioid-patient suicide- and overdose-related events in the Veterans Health Administration. … patient safety, and nurse outcomes at hospitals serving economically disadvantaged patients: a case for … June 21, 2023
Misdiagnosis in the emergency department: time for a system solution. … See More About The Topic
Emergency Departments
Health Care Executives and Administrators
Risk
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psnet.ahrq.gov/issue/medical-errors-and-quality-care-control-commitment
July 15, 2020 - This California Management Review article provides a framework for understanding the relationship between … 2023
Diagnostic errors, health disparities, and artificial intelligence: a combination for … November 13, 2019
Implementing universal suicide risk screening in a pediatric hospital … Interview
In Conversation with Lucy Savitz about Learning Health Systems for … June 12, 2019
Improving health care quality and safety for people with disabilities:
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psnet.ahrq.gov/periodic-issue/periodic-issue-460
October 30, 2024 - Suicide is considered a never event in healthcare settings. … Healthcare to identify modifiable risk factors contributing to inpatient suicide in Australia. … Study
Risk factors for wrong-site surgery: a study of 1,166 reports of informed … Risk factors for consent and schedule errors included low health literacy and nonstandardized forms and … The commentary summarizes risk factors for fall injuries among high-risk populations (such as older adults
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psnet.ahrq.gov/issue/patient-safety-chiropractic-teaching-programs-mixed-methods-study
November 04, 2020 - February 16, 2022
Safer prescribing and care for the elderly (SPACE): cluster randomised … December 15, 2021
Implementing universal suicide risk screening in a pediatric hospital … September 29, 2021
The evidence base for US Joint Commission hospital accreditation standards … February 10, 2015
Description and evaluation of an interprofessional patient safety course for
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psnet.ahrq.gov/issue/can-mindfulness-health-care-professionals-improve-patient-care-integrative-review-and
September 21, 2022 - June 30, 2011
Retrospective review for medication dose errors in pediatric emergency … Healthcare system-wide implementation of opioid-safety guideline recommendations: the case of urine drug screening … and opioid-patient suicide- and overdose-related events in the Veterans Health Administration. … November 25, 2020
Second victim support programs for healthcare organizations. … Unprofessional behaviors among tomorrow's physicians: review of the literature with a focus on risk
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psnet.ahrq.gov/issue/engaging-ethnic-minority-consumers-improve-safety-cancer-services-national-stakeholder
September 15, 2021 - Lack of patient engagement in care can place them at increased risk for safety events . … of existing techniques tailored to stakeholders (e.g., culturally specific content), and accounting for … Related Resources From the Same Author(s)
Do patient engagement interventions work for … More
Related Resources
Perspectives on Safety
Suicide … December 14, 2022
Multilevel factors associated with time to biopsy after abnormal screening
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psnet.ahrq.gov/node/49849/psn-pdf
January 01, 2019 - based on
review of the literature on both the clinical utility and the cost effectiveness of medical screening … Elderly patients are particularly at risk to have overlooked delirium (10,11), which can
either mimic … who are at risk for complications. … psnet.ahrq.gov//#references
The decision to trust a trainee is driven by characteristics of the learner, risks … Value of mandatory
screening studies in emergency department patients cleared for psychiatric admission
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psnet.ahrq.gov/issue/understanding-diagnostic-errors-medicine-lesson-aviation
December 30, 2014 - The authors begin with a general discussion about diagnostic errors before presenting a framework for … They advocate for greater study of this approach in patient care, realizing that many of the advantages … August 4, 2021
Identifying diagnostic errors in primary care using an electronic screening … Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient's Death by Suicide … July 10, 2008
View More
See More About The Topic
Risk Managers
Quality
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psnet.ahrq.gov/issue/measuring-errors-and-adverse-events-health-care
December 30, 2014 - This article provides a review and argument for a comprehensive multidimensional approach to measuring … December 30, 2014
The Safety Attitudes Questionnaire as a tool for benchmarking safety … March 2, 2012
Identifying diagnostic errors in primary care using an electronic screening … mortality in the United States: a secondary analysis of the Global Burden of Diseases, Injuries, and Risk … January 30, 2019
Incidence and method of suicide in hospitals in the United States.
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psnet.ahrq.gov/issue/chemotherapy-medication-errors-pediatric-cancer-treatment-center-prospective-characterization
January 22, 2017 - Related Resources From the Same Author(s)
A checklist to identify inpatient suicide … January 22, 2017
Effect of using the same vs different order for second readings of screening … December 21, 2014
Risk managers, physicians, and disclosure of harmful medical errors … September 7, 2016
An ethical framework for allocating scarce life-saving chemotherapy … and supportive care drugs for childhood cancer.
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psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-approach-data
February 26, 2025 - Compliance tracking of patient screenings for the five high-risk scenarios. … for an operating room fire. 1 A risk mitigation strategy was then designed in response to the five … Alert program with strong communication, collaboration, and literature-supported practices to mitigate risks … Compliance tracking of patient screenings for the five high-risk scenarios. … December 11, 2024
Patient Safety Innovations
Suicide Prevention
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psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
September 27, 2023 - Screening laboratory tests were reassuring, with negative urine drug screening and only mild elevation … Risk Mitigation Strategies for Recipients of Verbal Orders Readback and confirmation should be performed … these situations do not technically fit the traditional definition of “override,” they pose similar risks … medications (i.e., medications with a heightened risk of harm if used in error) Medications for which … WebM&M Cases
Walking Out of a Hospital After Attempted Suicide
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psnet.ahrq.gov/issue/physician-health-and-wellbeing-provide-challenges-patient-safety-and-outcome-quality-across
October 14, 2015 - This case series of physicians evaluated for fitness for duty found that health, independent of age, … The authors recommend screening for physician fitness based on overall physical and mental health rather … June 1, 2021
Development of a standardized, citywide process for managing smart-pump … October 24, 2017
Detecting and treating suicide ideation in all settings. … September 30, 2015
The PRONE score: an algorithm for predicting doctors' risks of formal
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psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-systemic-lupus-erythematosus-psychiatric-presentation
September 27, 2023 - disease) and the peripheral nervous system (e.g., Guillain-Barre syndrome, myasthenia gravis). 6 NPSLE risk … there was clinical suspicion of SLE based on the family history, and at least initially appropriate screening … presentations in patients with strong family history or personal history of SLE mandate appropriate laboratory screening … Healthcare Risk Management (Relias Media). Published August 1, 2022. … Suicide Risk Assessment
November 27, 2019
WebM&M Cases