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psnet.ahrq.gov/periodic-issue/periodic-issue-304
August 25, 2021 - Study
Breast cancer screening and overdiagnosis. … Study
Suicide and suicide attempts on hospital grounds and clinic areas. … Researchers reviewed 15 years of root cause analysis reports of all instances of suicide and suicide … Forty-seven suicides or suicide attempts were identified, and primary root causes included communication … breakdown and a need for improved suicide interventions.
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psnet.ahrq.gov/issue/standardized-admission-order-set-improves-perceived-quality-pediatric-inpatient-care
December 04, 2024 - October 31, 2014
A national mixed-methods evaluation of preparedness for general surgery … March 27, 2024
Implementing universal suicide risk screening in a pediatric hospital … A quality improvement initiative to reduce safety events among adolescents hospitalized after a suicide … October 6, 2016
Safety as a criterion for quality: The Critical Nursing Situation Index
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psnet.ahrq.gov/issue/incidence-versus-prevalence-based-measures-inappropriate-prescribing-veterans-health
March 18, 2020 - September 7, 2022
Dual health care system use and high-risk prescribing in patients with … December 21, 2017
Facility-level variation in potentially inappropriate prescribing for … Opioid Risk Mitigation (STORM) to improve opioid safety and prevent overdose and suicide. … 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/normalization-deviance-what-are-perioperative-risks
July 15, 2020 - Commentary
The normalization of deviance: what are the perioperative risks? … The normalization of deviance: what are the perioperative risks? … The normalization of deviance: what are the perioperative risks? … October 12, 2022
Performance of 3 sets of criteria for potentially inappropriate prescribing … November 13, 2019
Implementing universal suicide risk screening in a pediatric hospital
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psnet.ahrq.gov/issue/becoming-high-reliability-organization
May 04, 2015 - High reliability attainment is a stated goal for health care organizations. … 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. … July 14, 2009
Retrospective analysis of reported suicide deaths and attempts on Veterans … September 23, 2020
Quality measures for patients at risk of adverse outcomes in the Veterans
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psnet.ahrq.gov/issue/va-hospitals-flooded-complaints-about-care
August 09, 2017 - March 24, 2016
Report faults Children's Hospital for medication errors. … Development and applications of the Veterans Health Administration's Stratification Tool for … Opioid Risk Mitigation (STORM) to improve opioid safety and prevent overdose and suicide. … 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/eight-years-decreased-methicillin-resistant-staphylococcus-aureus-health-care-associated
March 23, 2012 - December 31, 2014
Evidence-based guidelines for fatigue risk management in emergency … , 2018
Evaluation of clinical practice guidelines on fall prevention and management for … Opioid Risk Mitigation (STORM) to improve opioid safety and prevent overdose and suicide. … 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/call-shift-fatigue-and-use-countermeasures-and-avoidance-strategies-certified-registered
March 15, 2023 - Citation
Related Resources From the Same Author(s)
Patient perception of fall risk … and fall risk screening scores. … October 26, 2011
Implementing universal suicide risk screening in a pediatric hospital … September 19, 2016
Support methods for healthcare professionals who are second victims … September 12, 2016
Caregiver fatigue: implications for patient and staff safety—part
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psnet.ahrq.gov/issue/medical-malpractice-claims-members-uniformed-services
November 14, 2011 - January 16, 2008
Zero Suicide Initiative. … March 13, 2024
Request for comments on the proposed measures and 2020 targets for the … 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. … October 21, 2015
View More
See More About The Topic
General Public
Risk
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psnet.ahrq.gov/issue/using-patient-safetyquality-improvement-model-assess-telehealth-psychiatry-and-behavioral
September 27, 2023 - Commentary
Using a patient safety/quality improvement model to assess telehealth for … Citation Text:
Using a patient safety/quality improvement model to assess telehealth for psychiatry … August 9, 2023
Systems approach to suicide prevention: strengthening culture, practice … Adults Residing in Nursing Homes
February 24, 2022
Implementing universal suicide … risk screening in a pediatric hospital.
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psnet.ahrq.gov/issue/moral-distress-compassion-fatigue-and-perceptions-about-medication-errors-certified-critical
November 09, 2015 - November 9, 2015
Patient perception of fall risk and fall risk screening scores. … July 22, 2010
Implementing universal suicide risk screening in a pediatric hospital. … October 19, 2022
eSIMPLER: a dynamic, electronic health record-integrated checklist for … Safety Innovations
eSIMPLER: a dynamic, electronic health record-integrated checklist for
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psnet.ahrq.gov/issue/race-differences-malpractice-event-database-large-healthcare-system
December 15, 2021 - Previous research has identified disparities in adverse events and patient safety risks for Black … lawsuits, findings suggest that employees are more likely to identify potential malpractice events for … December 1, 2021
Implementing universal suicide risk screening in a pediatric hospital … malpractice risk management and patient safety. … July 1, 2013
View More
See More About The Topic
Hospitals
Risk Managers
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psnet.ahrq.gov/issue/sentinel-events-memory-ben-case-study
July 01, 2016 - Written from the perspective of a risk manager, the author tells the story of a medication administration … communication with the bereaved parents, and the administrative steps taken subsequently to reduce the risk … June 10, 2015
Screening for adverse drug events: a randomized trial of automated calls … March 6, 2019
The risks to patient safety from health system expansions. … January 2, 2017
Suicide attempts and completions on medical-surgical and intensive care
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psnet.ahrq.gov/innovation/enhancing-support-patients-social-needs-reduce-hospital-readmissions-and-improve-health
February 26, 2025 - Care navigators tracked patients at the highest risk for readmission after discharge with the help of … The innovation also requires EHR-based resources and models for social needs screening tools. … The innovation also requires EHR-based resources and models for social needs screening tools. … Develop screening tools.
Develop a platform for tracking patient progress after discharge. … February 26, 2025
Patient Safety Innovations
Suicide
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psnet.ahrq.gov/issue/deficiencies-care-care-coordination-and-facility-response-patient-who-died-suicide-memphis-va
December 16, 2020 - Deficiencies in Care, Care Coordination, and Facility Response to a Patient Who Died by Suicide … of a patient who presented at an emergency room, was screened there, and referred to a clinic for further … September 4, 2019
Deficiencies in Emergency Preparedness for Veterans Health Administration … June 23, 2021
Keeping patients at risk for self-harm safe in the emergency department … September 4, 2019
Is it rational to pursue zero suicides among patients in health care
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psnet.ahrq.gov/issue/clinicians-expectations-benefits-and-harms-treatments-screening-and-tests-systematic-review
May 05, 2021 - Review
Clinicians' expectations of the benefits and harms of treatments, screening … Clinicians' Expectations of the Benefits and Harms of Treatments, Screening, and Tests: A Systematic … This systematic review found that providers' expectations surrounding the risks and benefits of tests … Clinicians' Expectations of the Benefits and Harms of Treatments, Screening, and Tests: A Systematic … and opioid-patient suicide- and overdose-related events in the Veterans Health Administration.
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psnet.ahrq.gov/periodic-issue/periodic-issue-328
February 23, 2022 - This systematic review identified three main risk factors for medication errors in the home: transition … This systematic review identified three main risk factors for medication errors in the home: transition … WebM&M Cases
Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and Primary … The commentary discusses the challenges of screening for suicide risk and the importance of continuity … of care for patients at risk of self-harm and suicide.
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psnet.ahrq.gov/issue/can-asking-emergency-physicians-whether-or-not-they-would-have-done-something-differently
July 01, 2016 - emergency physicians whether or not they would have done something differently (WYHDSD) be a useful screening … emergency physicians whether or not they would have done something differently (WYHDSD) be a useful screening … emergency physicians whether or not they would have done something differently (WYHDSD) be a useful screening … January 26, 2022
Analysis of risk factors for patient safety events occurring in the … June 28, 2023
Effect of an emergency department process improvement package on suicide
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psnet.ahrq.gov/issue/adenocarcinoma-situ-uterine-cervix-screening-and-diagnostic-errors-papanicolaou-smears
July 06, 2011 - Study
Adenocarcinoma in situ of the uterine cervix: screening and diagnostic errors … Adenocarcinoma in situ of the uterine cervix: screening and diagnostic errors in Papanicolaou smears. … July 21, 2021
Detecting and assessing suicide ideation during the COVID-19 pandemic. … July 26, 2023
Effect of an emergency department process improvement package on suicide … November 28, 2007
Risk factors for adverse drug events: a 10-year analysis.
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psnet.ahrq.gov/innovation/assessing-impact-virtual-medication-history-technicians-medication-reconciliation
December 01, 2021 - The best possible medication history (BPMH) is the gold standard approach for reconciling a patient … Length of stay, readmissions, and emergency department visits were similar for both groups. … May 5, 2021
Delayed or failure to follow-up abnormal breast cancer screening mammograms … Patient Safety Innovations
System Approaches to Social Determinants of Health Screening … Bundle
May 29, 2024
Patient Safety Innovations
Suicide