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psnet.ahrq.gov/issue/impact-electronic-medical-records-data-sources-adverse-drug-event-quality-measure
July 31, 2013 - September 2, 2009
State sepsis mandates—a new era for regulation of hospital quality. … June 21, 2017
Are physicians safely prescribing opioids for chronic noncancer pain? … Suicide Risk Assessment
November 27, 2019
Sepsis quality in safety-net hospitals … high-risk therapies in hospitalized children. … October 30, 2010
Understanding pharmacist decision making for adverse drug event (ADE
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psnet.ahrq.gov/issue/blame-culture-just-culture-health-care
January 23, 2017 - September 1, 2016
NICU medication errors: identifying a risk profile for medication errors … September 23, 2020
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Related Resources
Systems approach to suicide … January 11, 2023
Developing the Safer Dx Checklist of Ten Safety Recommendations for … May 4, 2022
The morbidity and mortality conference: opportunities for enhancing patient … September 23, 2020
Selected medication safety risks that can easily fall off the radar
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psnet.ahrq.gov/perspective/conversation-connor-wesley-rn-bsn-patient-safety-concerns-and-lgbtq-population
February 01, 2023 - When screening for the human papillomavirus (HPV), it is often based on sexual interaction, but providers … Members of the LGBTQ+ community are at higher risk for certain mental and physical health conditions. … clear to what extent LGBTQ+ patients are also at risk for harm when being treated within the healthcare … Patient discomfort in communicating with healthcare providers increases safety risks; the potential for … sexual histories of LGBTQ+ people for sexually transmitted disease (STD) and HIV screenings, and increase
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psnet.ahrq.gov/issue/teaching-quality-improvement-and-patient-safety-residency-education-strategies-meaningful
September 23, 2020 - Teaching quality improvement and patient safety in residency education: strategies for … Opioid Risk Mitigation (STORM) to improve opioid safety and prevent overdose and suicide. … April 12, 2017
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Related Resources
A dynamic risk management … approach for reducing harm from invasive bedside procedures performed during residency. … for a new role in graduate medical education.
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psnet.ahrq.gov/node/851971/psn-pdf
July 31, 2023 - Pica with sharp metal objects may represent a suicide attempt (e.g., in major depressive disorder) if … guidelines has not been identified as a risk factor
for aspiration in the literature.18,21
The duration … The hectic nature of the ED environment increases the
risk for communication errors. … Ascertainment of iron deficiency and depletion in blood donors
through screening questions for pica … Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the
Risk
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psnet.ahrq.gov/web-mm/delayed-evaluation-abdominal-pain-elderly-patient
February 26, 2020 - risks over- and under-triage. … (CMS) and The Joint Commission (TJC), demand screening for suicide risk, travel to high-risk countries … Patients with high-risk complaints (e.g., stroke symptoms) are prioritized for triage. … These patients should be considered “high risk,” and clinicians should have a low threshold for abdominal … Geriatric screening, triage urgency, and 30-Day mortality in older emergency department patients.
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psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
September 23, 2024 - limited to delayed recognition of and deterioration following breakdown of an anastomosis , patient fall risk … Agency for Healthcare Research and Quality. September 7, 2019. … Patient Safety Innovations
System Approaches to Social Determinants of Health Screening … September 23, 2024
Patient Safety Innovations
Suicide … Bundle
May 29, 2024
Patient Safety Innovations
Suicide
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psnet.ahrq.gov/perspective/health-plan-patient-safety-initiatives
July 10, 2024 - Medicare and Medicaid patients had significantly higher risk-adjusted rates of adverse events for a majority … Managed care and patient safety: risks and opportunities. … Before a provider is included in the health plan network, we are screening for quality and safety. … We look for any safety risks, especially when new drugs and devices first come out. … For example, if a state health department indicates lead screening as important for the state, they may
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psnet.ahrq.gov/periodic-issue/periodic-issue-278
February 10, 2021 - Study
Assessing reasons for decreased primary care access for individuals on prescribed … Patients transferred out of the intensive care unit (ICU)may be at risk for adverse events.Results from … Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient's Death by Suicide … This investigation examined care coordination, screening and other factors that contributed to a patient … death by suicide shortly after discharge from a Veteran’s Hospital.
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psnet.ahrq.gov/web-mm/preventable-rash
October 01, 2012 - Talking with patients about their sexual practices is a prerequisite for assessing their risk for STDs … and HIV, for screening appropriately, and for providing quality care. … Third, in order to make the diagnosis, appropriate screening for STDs must be done on a routine basis … We are not provided with information regarding additional STD screening tests (such as for gonorrhea … STD risk assessment and risk-reduction counseling by recently trained family physicians.
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psnet.ahrq.gov/issue/interventions-increase-clinical-incident-reporting-health-care
September 02, 2009 - September 2, 2009
Evaluating the prevalence of four recommended practices for suicide … September 20, 2011
Severe illness getting noticed sooner - SIGNS-for-Kids: developing … August 17, 2016
Interorganizational complexity and organizational accident risk: a literature
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psnet.ahrq.gov/issue/quality-assessment-spontaneous-triggered-adverse-event-reports-received-food-and-drug
August 07, 2024 - December 14, 2011
Crowding in the Emergency Department: Challenges for the Care of Children … Perspectives on Safety
Annual Perspective
Technology as a Tool for … December 21, 2018
Screening for medication errors using an outlier detection system. … March 4, 2015
Validating administrative data for the detection of adverse events in older … October 29, 2014
Risk factors for hospital admissions associated with adverse drug events
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psnet.ahrq.gov/web-mm/confusion-acetaminophen
December 01, 2009 - study evaluating more than 28,000 children treated with acetaminophen failed to show any increased risk … identifying elevated acetaminophen concentrations in the blood relative to the last dose may reveal a risk … for hepatotoxicity. … acetaminophen for a child. … WebM&M Cases
Walking Out of a Hospital After Attempted Suicide
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psnet.ahrq.gov/node/49398/psn-pdf
May 01, 2003 - revealed that Patient #1 was HIV and Hepatitis B Virus (HBV) positive and that the collision was a suicide … While the risk for patients and surgeons may be low in controlled settings (operating rooms and invasive … The cost of
changing obviously contaminated equipment may seem high for such a relatively small risk … Risks for exposures to and infection with HIV among health care providers in the
emergency department … Preventive care in the emergency
department: should emergency departments conduct routine HIV screening
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psnet.ahrq.gov/issue/higher-accuracy-complex-medication-reconciliation-through-improved-design-electronic-tools
April 05, 2017 - The authors advocate for conducting this type of rigorous user testing to ensure electronic health record … April 19, 2017
Surviving Sepsis Campaign: international guidelines for management of … December 21, 2016
Analysis of suicides reported as adverse events in psychiatry resulted … June 16, 2021
Selected medication safety risks that can easily fall off the radar screen—part
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psnet.ahrq.gov/issue/retained-guidewires-veterans-health-administration-getting-root-problem
March 13, 2013 - Electronic medical record alert associated with reduced opioid and benzodiazepine coprescribing in high-risk … 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.
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psnet.ahrq.gov/issue/using-failure-mode-and-effect-analysis-identify-potential-failures-psychiatric-hospital
June 22, 2017 - Failure mode and effect analysis (FMEA) is a common way to identify error risk. … completed by two groups, ED staff and non-ED staff, to determine if a multi-professional team could be used for … December 18, 2019
Screening for medication errors using an outlier detection system. … February 15, 2023
Is it time for the mental health field to consider unplanned discharge … April 20, 2022
Safe clinical practice for patients hospitalised in mental health wards
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psnet.ahrq.gov/issue/disclosing-large-scale-adverse-events-us-veterans-health-administration-lessons-media
August 18, 2021 - Electronic medical record alert associated with reduced opioid and benzodiazepine coprescribing in high-risk … 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.
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psnet.ahrq.gov/web-mm/errors-sepsis-management
November 03, 2015 - In addition, patients with an elevated risk of health care–associated infections or who reside in an … vancomycin or linezolid as she had been hospitalized 3 weeks prior to her current presentation and was at risk … To mitigate this, the use of a sepsis screening tool is recommended by the SSC. … The specific elements of the screening tool are not as important as the fact that it reminds providers … WebM&M Cases
Walking Out of a Hospital After Attempted Suicide
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psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia
August 06, 2014 - Because of the drug's risks for adverse effects, clozapine must be prescribed and dispensed in accordance … For these medications, a Risk Evaluation and Mitigation Strategy (REMS) program may apply. … There was also a lack of quality control or independent check system for this high-risk drug. … serious, known medication safety risks. … Related Resources
WebM&M Cases
Challenging Case of Multiple Suicide