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psnet.ahrq.gov/innovation/clinical-pharmacy-specialists-provide-transitional-care-and-improve-medication-safety
October 30, 2024 - this innovation included recently discharged patients considered high-risk for ADEs and readmission. … patients with HF or COPD, and other patients deemed to be at high risk for readmission. … Additionally, these inpatient pharmacists focused on disease state counseling for high-risk patients … Patient Safety Innovations
System Approaches to Social Determinants of Health Screening … Bundle
May 29, 2024
Patient Safety Innovations
Suicide
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psnet.ahrq.gov/issue/salutary-tale-mistaken-identity-testicular-cancer
June 01, 2022 - October 28, 2020
Improving shared situation awareness for high-risk therapies in hospitalized … January 27, 2016
The experiences of risk managers in providing emotional support for … August 4, 2010
Intravenous chemotherapy preparation errors: patient safety risks identified … December 7, 2016
Evidence-based guidelines for fatigue risk management in EMS: formulating … April 2, 2014
Overdiagnosis in low-dose computed tomography screening for lung cancer
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psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care
November 25, 2020 - First, ED crowding led to a significant delay for a patient with a high-risk presentation. … Most observers would agree that a 5-hour delay for a patient with high-risk features is unacceptable … In July 2019, TJC began requiring EDs to screen all patients for suicide risk (National Patient Safety … Those patients identified as high-risk for suicide are designated ESI-2 even if they appear comfortable … Suicide Prevention. Website: http://www.jointcommission.org . Accessed February 3, 2020.
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psnet.ahrq.gov/perspective/conversation-withamy-helwig-about-health-plan-patient-safety-initiatives
July 10, 2024 - 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 … Medicare and Medicaid patients had significantly higher risk-adjusted rates of adverse events for a majority … Managed care and patient safety: risks and opportunities.
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psnet.ahrq.gov/web-mm/bandemia-harbinger-stercoral-colitis-and-impending-perforation
November 25, 2020 - Although this decision was supported by the patient and her family, it involved significant risk for … In many EDs, a nurse or physician calls patients who are discharged with high-risk findings but without … bacterial infection among patients at risk, healthcare organizations should consider electronic health … A Fatal Twist in Pseudohyperkalemia
December 31, 2024
Reducing the risk … 1, 2018
WebM&M Cases
Failed Interpretation of Screening
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psnet.ahrq.gov/Issues
June 23, 2021 - The psychological experiences of nurses after inpatient suicide: a meta-synthesis of qualitative research … The psychological experiences of nurses after inpatient suicide: a meta-synthesis of qualitative research … Safe opioid prescribing: a prognostic machine learning approach to predicting 30-day risk after an opioid … sexually transmitted infection (STI) screening after being informed by the health department that he … Safety in Home Dialysis
April 2021
This piece discusses how the program mitigates safety risks
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psnet.ahrq.gov/issues
June 23, 2021 - The psychological experiences of nurses after inpatient suicide: a meta-synthesis of qualitative research … The psychological experiences of nurses after inpatient suicide: a meta-synthesis of qualitative research … Safe opioid prescribing: a prognostic machine learning approach to predicting 30-day risk after an opioid … sexually transmitted infection (STI) screening after being informed by the health department that he … Safety in Home Dialysis
April 2021
This piece discusses how the program mitigates safety risks
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psnet.ahrq.gov/issue/relationships-among-clinician-delay-diagnosis-breast-cancer-and-tumor-size-nodal-status-and
March 08, 2017 - March 8, 2017
Centers for Disease Control and Prevention Guideline for the Prevention … May 7, 2014
Is it rational to pursue zero suicides among patients in health care? … for postoperative complications. … January 11, 2023
Multilevel factors associated with time to biopsy after abnormal screening … Patient Safety & Risk Reduction.
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psnet.ahrq.gov/node/73104/psn-pdf
January 04, 2021 - A fear of infection has prevented patients from seeking routine medical care and
screenings,13,14 and … missed due to the pandemic.15 The pandemic has also been attributed to
delays in preventive cancer screenings … Additionally, as providers
are also at high risk for substance misuse/substance use disorders, resources … the prevalence of comorbid conditions, as well
as behavioral health outcomes, such as overdose and suicide … COVID-19: people at increased risk. Centers for Disease Control and Prevention.
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psnet.ahrq.gov/issue/impact-medical-mistakes-navigating-work-family-boundaries-physicians-and-their-families
January 23, 2019 - July 23, 2014
Risks are high at low-volume hospitals. … March 8, 2006
Insulin treatment as a tracer for identifying latent patient safety risks … November 19, 2008
Building a Memory: Preventing Harm, Reducing Risks and Improving Patient … May 5, 2021
Assessing reasons for decreased primary care access for individuals on prescribed … September 16, 2020
Opioid prescribing after childbirth and risk for serious opioid-related
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psnet.ahrq.gov/periodic-issue/periodic-issue-276
January 29, 2021 - J Healthc Risk Manag . 2021; 40(4) :30-37 . … screening patients), scope of practice, and use of telemedicine. … assessment and workflow management for high-risk medical procedures during the pandemic and prevention … Fatigue among health care workers can increase risk of errors. … This article examined reports of COVID-19 vaccine errors to highlight common risks that are likely to
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psnet.ahrq.gov/node/60066/psn-pdf
March 25, 2020 - First, ED crowding led to a significant
delay for a patient with a high-risk presentation. … Most observers would agree that a 5-hour delay for a patient with high-risk features is
unacceptable … In July 2019, TJC began requiring EDs to screen
all patients for suicide risk (National Patient Safety … Those patients identified as high-risk
for suicide are designated ESI-2 even if they appear comfortable … Suicide Prevention. Website: http://www.jointcommission.org. Accessed
February 3, 2020.
21.
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psnet.ahrq.gov/perspective/harm-reduction-strategies-improve-safety-people-who-use-substances
October 30, 2024 - The services often include access to naloxone for overdose prevention, screening and treatment for injection-related … Specific strategies can include screening for substance use disorders (SUD) in all patients, educating … People took tremendous risks then and have continued to take risks for the last few decades to make sure … Safety
March 29, 2023
Perspectives on Safety
Suicide … Safety
Interview
In Conversation with Edwin Boudreaux about Suicide
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psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-and-performance
September 23, 2024 - found that experiencing two or more adverse events was associated with a threefold increase in the risk … in the ICU. 5 Another study found that staff in critical care environments often have to make high-risk … Patient Safety Innovations
System Approaches to Social Determinants of Health Screening … Bundle
May 29, 2024
Patient Safety Innovations
Suicide … Mitigation Using the Anesthesia Risk Alert Program: Applying a Proactive Approach With Data Review
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psnet.ahrq.gov/web-mm/overdose-oxygen
August 02, 2023 - further explanation of the risks of excess oxygen in patients with severe COPD). … For most COPD patients, a target saturation range of 88%–92% will avoid the risks of hypoxia and hypercapnia … Suicide Risk Assessment in Emergency and Primary Care Settings
January 7, 2022 … March 17, 2010
Estimating breast cancer overdiagnosis after screening mammography among … November 30, 2016
Operating room traffic as a modifiable risk factor for surgical site
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psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
July 23, 2024 - For example, a goal of 90% adherence may be reasonable for a specific measure because 100% adherence … Patient Safety Innovations
System Approaches to Social Determinants of Health Screening … September 23, 2024
Patient Safety Innovations
Suicide … Resources
Patient Safety Innovations
Combined Proactive Risk … Summary
July 23, 2024
Patient Safety Innovations
Suicide
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psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care
April 01, 2008 - Appreciate the value of a high-yield screening neurologic exam in primary care. … cord, which revealed critical cervical (neck) cord compression, so tight that it placed the patient at risk … This missed diagnosis stemmed from performing an incomplete screening neurologic exam and overlooking … Components of a high-yield neurologic screening exam are listed in Table 2 and should be performed … Sample screening neurologic exam for PCPs.
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psnet.ahrq.gov/perspective/conversation-elizabeth-salisbury-afshar-about-harm-reduction-strategies-improve-safety
October 30, 2024 - People took tremendous risks then and have continued to take risks for the last few decades to make sure … The services often include access to naloxone for overdose prevention, screening and treatment for injection-related … Specific strategies can include screening for substance use disorders (SUD) in all patients, educating … Safety
November 27, 2023
Perspectives on Safety
Suicide … Safety
Interview
In Conversation with Edwin Boudreaux about Suicide
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psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
February 10, 2021 - Similarly, physicians recommended timelier follow-up for cancer screening when presented with the frequency … High-risk medications: Anticoagulation
Because the clinician was concerned for a cardiac etiology of … Without a clear indication for anticoagulation, these high-risk medications should not have been administered … currently in use at our hospital, requires providers ordering an MRI study to complete a contraindication screening … patients at increased risk of bleeding.
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psnet.ahrq.gov/node/841493/psn-pdf
December 14, 2022 - higher in-person follow-up care raising patient safety concerns.4
However, it is believed that these risks … delayed-diagnosis-setting-virtual-care-remembering-physical-examination
https://psnet.ahrq.gov//#4
https://psnet.ahrq.gov//#5
screening … for mental and behavioral health issues with questionnaires administered prior to encounters for
depression … Strategies to Enhance Patient Safety
https://psnet.ahrq.gov/issue/improvement-brief-detecting-and-assessing-suicide-ideation-during-covid … Remote patient monitoring for ED discharges in the COVID-19
pandemic.