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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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www.ahrq.gov/patient-safety/settings/emergency-dept/frequent-use.html
July 01, 2017 - These identified “high-risk patients” were then screened by a research assistant using the Screening … Screening for the first five risk factors was achieved through a combination of patient interviews and … In addition to the information required for completion of the Screening Checklist, the research team … Close to half (44%) of the screened patients had none of the six risk factors included in the screening … Return to Contents
ED Discharge High-Risk Screening Checklist
|___| Frequent ED User (FEDU
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/implementation-guides/implementation-guide2/implguide2pt1.html
September 01, 2014 - The Problem
Youth with complex behavioral health needs face a range of challenges and are at risk … friendships, drop out of high school, come in contact with the juvenile justice system, and attempt suicide … such as foster care, are often taking more than one psychotropic medication, putting them at increased risk … States often use a standardized screening tool, such as the Child and Adolescent Service Intensity Instrument … For example, several studies found that wraparound services are more beneficial for some youth, such
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integrationacademy.ahrq.gov/products/playbooks/moud-playbook/implementing-treatment/chronic-pain
January 01, 2019 - the Treatment Plan
Individuals with chronic non-cancer pain treated with opioids are at higher risk … guidance on mental health screening and treatment approaches, see the Counseling and Other Psychosocial … the patient's medication for OUD. … Operational Systems and Workflows
Screening and Diagnosis
Engaging Patients in Treatment … for OUD
Pharmacotherapy
Mitigating Overdose Risk
Prevent and Respond to
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integrationacademy.ahrq.gov/products/playbooks/moud-playbook/implementing-treatment/person-centered-care
October 01, 2025 - Documents discussions with the patient about the risks and benefits of having a shared record and the … Be prepared to talk with patients about the risks and benefits of information sharing and confidentiality … that uses dialogue to compare the benefits, harms, and risks of each option to help explore what matters … Operational Systems and Workflows
Screening and Diagnosis
Engaging Patients in Treatment … for OUD
Pharmacotherapy
Mitigating Overdose Risk
Prevent and Respond to
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psnet.ahrq.gov/issue/laboratory-session-improve-first-year-pharmacy-students-knowledge-and-confidence-concerning
September 08, 2021 - 17, 2022
WebM&M Cases
Multiple Missed Opportunities for … Suicide Risk Assessment in Emergency and Primary Care Settings
January 7, 2022 … November 24, 2021
Identifying trigger concepts to screen emergency department visits for … June 23, 2021
Medication errors at hospital admission and discharge: risk factors and
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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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effectivehealthcare.ahrq.gov/sites/default/files/pdf/standardized-library-depression-white-paper.pdf
May 01, 2020 - Survival Death from suicide Patient with a diagnosis of major depression or dysthymia who died from suicide … Supplemental assessments of suicide ideation and behavior should be completed for
patients who screen … positive for suicide ideation on the PHQ-9 or when a clinician has
concerns about suicidality. … should be completed using
an appropriate, brief, validated instrument, such as the Concise Health Risk … Includes nonfatal suicide attempts/suicide attempt behaviors,
planning/preparatory acts, active suicidal
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effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/standardized-library-depression-white-paper.pdf
May 01, 2020 - Survival Death from suicide Patient with a diagnosis of major depression or dysthymia who died from suicide … Supplemental assessments of suicide ideation and behavior should be completed for
patients who screen … positive for suicide ideation on the PHQ-9 or when a clinician has
concerns about suicidality. … should be completed using
an appropriate, brief, validated instrument, such as the Concise Health Risk … Includes nonfatal suicide attempts/suicide attempt behaviors,
planning/preparatory acts, active suicidal
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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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effectivehealthcare.ahrq.gov/sites/default/files/pdf/anxiety-children_research-protocol.pdf
September 12, 2016 - Studies
included by either reviewer will be retrieved for full-text screening. … Assessment of Methodological Risk of Bias of Individual Studies
We will evaluate the risk of bias of … For
RCTs, we plan to apply the Cochrane Collaboration’s Risk of Bias tool to assess
sequence generation … the methodological
limitations of the studies (i.e., risk of bias); precision (based on the size of … Clinical response and risk for reported
suicidal ideation and suicide attempts in pediatric antidepressant
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www.uspreventiveservicestaskforce.org/uspstf/document/evidence-summary9/alcohol-misuse-screening-and-behavioral-counseling-interventions-in-primary-care-2013
September 25, 2012 - neuropathy, cardiomyopathy, anemia, osteoporosis, cognitive impairment, depression, insomnia, anxiety, suicide … The National Institute on Alcohol Abuse and Alcoholism has proposed guidelines 17 to limit the risks … Quantifying the risks associated with exceeding recommended drinking limits. … Brief physician advice for high-risk drinking among young adults. … Consumption levels that increase the risk for health consequences.
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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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integrationacademy.ahrq.gov/products/topic-briefs/age-0-5-behavioral-development
February 01, 2025 - During these visits, Family Connects nurses perform physical health assessments; conduct screenings for … The M-CHAT-R/F is a 2-stage parent-report screening tool to assess risk for Autism Spectrum Disorder. … SEEK screens parents for prevalent psychosocial problems that are risk factors for child maltreatment … the rates of screening, positive risk identified, and interventions provided. … The example risk registry in Figure 2 (below) is based on completed SWYC screening tools.
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/antipsychotics-adults_research-protocol.pdf
December 01, 2010 - behaviors, and death by suicide. … disorder, what is the comparative effectiveness and risks of
FGAs vs. … behaviors, and death by suicide … The risk of bias for all other studies will be rated as
unclear. … Data Synthesis
For each study, we will analyze comparisons between dichotomous outcomes by
using risk
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023-nhqdr-es-rev.pdf
January 01, 2023 - at-risk hospitals … • Cancer screening:
■ Nationally, there were no statistically significant differences in screening … cancer screening with mammogram decreased between 2019 and
2021 for Hispanic (78.2% to 73.8%), NH-Asian … Between 2019 and 2021, cervical cancer screening rates decreased by 4.9% for
people in large central … These are
evidence-based treatments that reduce opioid use and risk for overdose.
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/evidence-summary-cer-200-post-acs-depression.pdf
November 01, 2017 - Review
Patients who are diagnosed with acute
coronary syndrome (ACS) are at increased
risk for mental … Post-ACS Screening Strategies
A number of screening tools for depression
have been developed. … patients
Instruments
Screening tools
for depression
Diagnostic accuracy
Sensitivity, specificity … [PHQ])
may be almost as accurate for diagnostic screening as
using the full instrument. … This suggests that other screening instruments
that may be more feasible for use in general medical
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digital.ahrq.gov/sites/default/files/docs/citation/cds-connect-year3-final-report-2019.pdf
January 01, 2019 - about the risks for
developing diabetes and how to reduce those risks; (2) information on the role diabetes … Risk Screening
Order Set
VHA
Structured
04/27/2018
Mental Health: Suicide Risk Assessment
Documentation … mental-health-iraq-afghanistan-post-deployment-screen-documentation-template
https://cds.ahrq.gov/cdsconnect/artifact/mental-health-positive-suicide-risk-screening-order-set … https://cds.ahrq.gov/cdsconnect/artifact/mental-health-positive-suicide-risk-screening-order-set
https … ://cds.ahrq.gov/cdsconnect/artifact/mental-health-suicide-risk-assessment-documentation-template
https