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psnet.ahrq.gov/issue/validation-discharge-summary-term-search-method-detect-adverse-events
December 06, 2017 - likely to reflect quality or safety problems without requiring the same investment of resources as would screening … readmissions within 30 days of discharge: prevalence, preventability, type of medication errors and risk … December 20, 2023
Risk-adjusted cumulative sum for early detection of hospitals with … November 1, 2023
Adverse drug events caused by three high-risk drug-drug interactions … November 18, 2020
The emergency department trigger tool: a novel approach to screening
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psnet.ahrq.gov/web-mm/when-psychiatric-symptoms-are-not
September 20, 2011 - practice continues to rely on a careful history and physical examination guided by epidemiological risk … #1: The mistake of neglecting the medical risks associated with older age. … Widespread use of extensive laboratory screening does not seem indicated in the majority of psychiatric … for medical staff. … Screening laboratory evaluation in psychiatric patients: a review.
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psnet.ahrq.gov/web-mm/buprenorphine-and-medically-ill-patient
August 20, 2018 - alcohol and/or benzodiazepines, the administration of opioids might be complicated and represent greater risk … When this risk is elevated, monitoring should be increased or the patient transferred to a higher level … the lowest possible dose to alleviate withdrawal and craving, and education of the patient about the risks … The risk is increased in patients with pre-existing respiratory compromise and with some abused drugs … Related Resources
Patient Safety Innovations
Suicide
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psnet.ahrq.gov/node/49632/psn-pdf
July 01, 2011 - Few studies have examined the safety
risks presented by the type of handoff in this case—the academic … Identify and Prioritize Higher Risk Patients. … Does housestaff discontinuity of care increase
the risk for preventable adverse events? … safety and resident education during the academic year-
end transfer of outpatients: lessons from the suicide … Academic year-end outpatient transfers: identifying and improving
follow-up of high risk psychiatry
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psnet.ahrq.gov/web-mm/good-nights-sleep-gone-wrong
September 01, 2015 - Anger, PharmD
This case highlights the risks associated with sleep aid utilization in hospitalized … Common adverse effects of sleep aids include residual daytime sedation leading to increased risk for … Patients with certain comorbid conditions may be at an increased risk for adverse effects from medications … Clinical judgment is needed to weigh the potential risks and benefits of utilizing such agents and to … Older patients are at an increased risk for adverse effects and poor outcomes, such as residual daytime
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psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges
March 27, 2024 - One of the most common potential applications of AI for patient safety is risk prediction—for example … Risks to Patient Safety While the potential for improving patient safety is high, AI also comes with … End-to-end lung cancer screening with three-dimensional deep learning on low-dose chest computed tomography … Safety
November 27, 2023
Perspectives on Safety
Suicide … Safety
Interview
In Conversation with Edwin Boudreaux about Suicide
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psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
February 26, 2025 - which can delay diagnosis and treatment. 10 A study in Michigan found that patients at the greatest risk … . 1
Innovation Patient Safety Focus
The lack of necessary clinical follow-up after a key cancer screening … Without input from a primary care provider, they did not know other patient risk factors. … Without knowing all the risk factors, the team could not determine clinical necessity for follow-up testing … February 26, 2025
Patient Safety Innovations
Suicide
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psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm
April 01, 2018 - But maybe less attention on what happens in the hospital that may set patients up to be at risk for post-hospital … patients based on clinical histories, demographics, or screening tools, and then to implement targeted … Improvements in health care technology enhance our abilities to assess risks and deliver interventions … Conclusion
Besides facing the risks of hospitalization, patients also face significant risks upon discharge … Safety
Interview
In Conversation with Edwin Boudreaux about Suicide
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psnet.ahrq.gov/perspective/cybersecurity-and-how-maintain-patient-safety
March 27, 2024 - We spoke to them about the risks of cybersecurity to patient safety and how organizations can prepare … John Riggi: I am the national advisor for cybersecurity and risk at the American Hospital Association … Leaders and staff have to really understand the enterprise-risk nature of cyber risk. … 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/two-pills-same-drug
May 27, 2011 - This risk also intensifies during transitional periods when institutions are replacing one ordering system … A primer on aspects of cognition for medical informatics. … December 21, 2016
Analysis of suicides reported as adverse events in psychiatry resulted … December 1, 2011
WebM&M Cases
Miscalculated Risk … Topic
Hospitals
Physicians
Pharmacists
Ordering/Prescribing Errors
Specific to High-Risk
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psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-compartment-syndrome-after-lower-leg-fracture
November 25, 2020 - with its own risks that some patients would find unacceptable. … Effective CS screening tools should therefore maximize sensitivity to reduce the false negative rate … teams: Identify patients at risk for CS and communicate concern with all team members. … ) who care for patients at risk for CS. … Take-Home Points In patients at risk for compartment syndrome, maintain a high index of suspicion and
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psnet.ahrq.gov/perspective/equity-patient-safety
September 24, 2024 - In healthcare, algorithms use patient variables to estimate risk for various outcomes, such as the worsening … In a qualitative study on race- and ethnicity-based algorithms in healthcare, respondents found risk … negative tone and potentially stigmatizing language in the electronic health record alongside other risk … Resources
Patient Safety Innovations
Combined Proactive Risk … February 26, 2025
Patient Safety Innovations
Suicide
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psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art
January 17, 2018 - often a day or two) in diagnosis as one awaits the test results; second, the patient is exposed to the risk … These risks include both the obvious unwarranted financial expense to the patient and the healthcare … patients necessitated by the 80-hour work week imposed on physicians in training might compound the risk … August 21, 2024
The physiology of failure: identifying risk factors for mortality in … May 1, 2003
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See More About The Topic
Physicians
Risk
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psnet.ahrq.gov/perspective/conversation-david-w-bates-about-are-we-safer-today
February 26, 2025 - For example, with pressure injuries, wetness in the bed dramatically increases the risk that somebody … there is still a lot of risk associated with surgery. … Automated identification of adults at risk for in-hospital clinical deterioration. … used the best available methodology to identify CLABSIs for the populations most at risk. 3 Second, … Safety
Interview
In Conversation with Edwin Boudreaux about Suicide
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psnet.ahrq.gov/perspective/are-we-safer-today
February 26, 2025 - used the best available methodology to identify CLABSIs for the populations most at risk. 3 Second, … For example, with pressure injuries, wetness in the bed dramatically increases the risk that somebody … there is still a lot of risk associated with surgery. … Automated identification of adults at risk for in-hospital clinical deterioration. … Safety
Interview
In Conversation with Edwin Boudreaux about Suicide
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psnet.ahrq.gov/web-mm/do-not-disturb
February 03, 2011 - Screening applicants for medical school and dismissing a few students each year weed out some of those … Moreover, good teamwork mitigates the risks of physician (or other staff) failures that disrupt team … These are more serious risks to quality patient care than failing to provide continuous care to patients … Unfortunately, there is some evidence that the physicians with the greatest risk for incompetent professionalism … Resources
Patient Safety Innovations
Combined Proactive Risk
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psnet.ahrq.gov/perspective/conversation-cindy-brach
December 27, 2019 - For example, in the case of accreditation auditors. … from the failure to address culture, language, and health literacy include diagnostics errors, missed screenings … a necessary surgery. [13] With growing diversity in patient populations across the country, the risk … Safety
Interview
In Conversation with Edwin Boudreaux about Suicide … Conversation with...Dean Schillinger, MD
March 22, 2009
Follow-up of abnormal screening
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psnet.ahrq.gov/perspective/virtual-nursing-improving-patient-care-and-meeting-workforce-challenges
August 30, 2023 - Prior to the pandemic, the Agency for Healthcare Research and Quality (AHRQ) noted the potential for … For example, a telehealth initiative was established to improve access to telehealth for high-risk … I took a little break from nursing work for strategy for a couple of years many years ago. … Sue Schuelke: We’ve also been using immersive virtual reality for relaxation and for education for our … Summary
July 23, 2024
Patient Safety Innovations
Suicide
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psnet.ahrq.gov/perspective/conversation-kathleen-sanford-and-sue-schuelke-about-virtual-nursing
August 30, 2023 - I took a little break from nursing work for strategy for a couple of years many years ago. … Sue Schuelke: We’ve also been using immersive virtual reality for relaxation and for education for our … Prior to the pandemic, the Agency for Healthcare Research and Quality (AHRQ) noted the potential for … For example, a telehealth initiative was established to improve access to telehealth for high-risk … Summary
July 23, 2024
Patient Safety Innovations
Suicide
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psnet.ahrq.gov/perspective/workplace-safety-health-care
January 01, 2017 - Download Citation
Perspective
The patient safety movement has highlighted the risks … But, importantly, workers face risks as well.( 1,2 ) Although debate continues regarding whether worker … we were really at the top of our game in health care, we would say to people "Do not put yourself at risk … And so I said to him, "That means 22% of the time people are at risk." Is that okay? … June 11, 2014
Miscount incidents: a novel approach to exploring risk factors for unintentionally