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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/otimefallspx-implmatls.pdf
November 02, 2017 - • Develop interventions specific to the risk factors to mitigate falls risk. … resident falls risk
Communication of falls risk to clinical and care plan teams
Creation … ____
Therapy _____
CNAs _____
Nurses _____
Therapy _____
CNAs _____
Documentation regarding risks … Weekly Falls Risk or Safety Meetings
Quarterly Summary of Falls Risk Factors by Unit or Facility … populated on the report to ensure that data on the report agree with staff
knowledge of residents’ health/risks
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b1_combo_applyingqis.pdf
March 01, 2016 - Hospital A has a risk-
adjusted rate of 0.025 = (0.02/0.04) * 0.05) and Hospital B has a risk adjusted … defined above,
ˆˆk k kj je Xβ= the predicted probability of QI k
occurring on discharge j given the risks … )
present in discharge j where ˆ kβ is a vector of
parameter estimates from a regression of the risks … of the risk-adjusted rate over time. … Also used instead of the risk-
adjusted rate for comparing with
others if the risk-adjusted rate is
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ce.effectivehealthcare.ahrq.gov/pqmp/measures/index.html?page=0
April 04, 2024 - Sexual Activity
(2)
Adolescent Tobacco Use
(1)
Availability of Services
(14)
High-Risk … Excellence for Pediatric Quality Measurement (CEPQM) NQF Endorsement Number: 3136
Initial Risk … Pregnancies Measure Domain: Availability of Services Measure Subdomain: High-Risk Obstetrics COE: … Pregnancies Measure Domain: Availability of Services Measure Subdomain: High-Risk Obstetrics COE: … Mount Sinai Collaboration for Advancing Pediatric Quality Measures (CAPQuaM)
High-Risk Deliveries
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ce.effectivehealthcare.ahrq.gov/pqmp/measures/index.html
May 01, 2024 - Sexual Activity
(2)
Adolescent Tobacco Use
(1)
Availability of Services
(14)
High-Risk … Excellence for Pediatric Quality Measurement (CEPQM) NQF Endorsement Number: 3136
Initial Risk … Pregnancies Measure Domain: Availability of Services Measure Subdomain: High-Risk Obstetrics COE: … Pregnancies Measure Domain: Availability of Services Measure Subdomain: High-Risk Obstetrics COE: … Mount Sinai Collaboration for Advancing Pediatric Quality Measures (CAPQuaM)
High-Risk Deliveries
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ce.effectivehealthcare.ahrq.gov/innovations/will-work/how-to.html
February 01, 2021 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … topics in this section
Innovations
Downloadable Databases
Connecting Those at Risk … What are the risks?
Can we do it here?
Are we ready for this change? … Potential Risks
What types of risk will we face?
How do we assess potential risks?
III.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module3/module3_slides_best-practices.pptx
June 16, 2017 - Fall Risk Assessment
‹#›
Step 1: Fall Risk Screening/Assessment
Use a reliable, prospectively … Other risks
IV pole
Orthostatic hypotension
Oxygen tubing
Clutter in the patient’s room
Vision problems … 25-45: Moderate risk
>45: High risk ______
* Weak gait: Short steps (may shuffle), stooped but able … 25-45: Moderate risk
>45: High risk 50
‹#›
Assessment of Risk Factors in Your Hospital
The questions … Identify key elements of a fall risk factor assessment.
Choose a tool for assessing risk factors.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/ltvv-litreview.docx
January 01, 2017 - patients, or for high-risk surgery. … Thus, the risks and benefits of lung-protective ventilation need to be balanced in each individual patient … lung-protective ventilation, as compared with 55 of 200 (27.5%) assigned to nonprotective ventilation (relative … intubation for acute respiratory failure, as compared with 34 (17.0%) assigned to nonprotective ventilation (relative … Therefore, the risks and benefits should be balanced for each patient.
23. Kilickaya O, Gajic O.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module2/mod02-business-case-worksheet.pdf
April 01, 2016 - Adapt the business case to the audience being addressed, whether it is the CEO, risk manager, or frontline … – Alignment of the plan to the organization’s
strategic and risk/quality/patient safety goals. … Implementation Risk
■ Assessment of the Implementation Risk should
address … risks associated with allocating resources
(human and other) to implement, spread, or
sustain the … )
■ Include potential risks to the organization if the
practices and principles are not fully integrated
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Bayley.pdf
January 01, 2004 - Summary scores from the FMEA are presented in Table 1, which shows the
relative risk for each step as … risks on the
highest risk steps. … Across all steps, risks were estimated to decrease by 45 percent.
Table 2. … The FMEA predicted that the IT strategy implemented in
one IDS reduced risk scores in the highest risk … Managing the risks of organizational
accidents.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/factraining_slides.pptx
December 01, 2014 - Does information exist to identify residents at risk?
How can this information be used? … preventing adverse events
Proactive rather than reactive
Identify residents with recent changes in risks … Profile risks for each resident in report
Prioritize residents for possible changes to their treatment … Worksheet
Each Self-Assessment worksheet is designed to help nursing home staff review how they:
Screen for risks … associated with each of the On-Time program’s adverse events
Mitigate those risks
Prioritize residents
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ce.effectivehealthcare.ahrq.gov/research/publications/pubcomguide/pcguide1.html
May 01, 2022 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … activities including: research projects (surveys, interviews, questionnaires, epidemiology studies, health risk … Report results in comparative terms to describe the magnitude of effect (units, relative risks, absolute … For example, if the risk of cancer in men is 3/1,000 and the risk in women is 6/1,000, then the relative … risk for women is 2 (twice the risk in men).
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ce.effectivehealthcare.ahrq.gov/teamstepps/lep/traintrainers/lepigstafftrain.html
October 01, 2020 - High-Risk Settings and Situations .
Added Risk for LEP Patients . … Ask participants: What are the risks in this situation? What was handled well? … Discussion:
What are the risks to the patient in this scenario?
What could go wrong? … I'm uncomfortable...This is a safety issue..." it means that we need to pause and make sure no safety risks … Team goals, plans, and risks—what is to be accomplished, who will do it, and what the potential risks
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ce.effectivehealthcare.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-slides.html
December 01, 2017 - How will you reduce the risk of it happening again?
How will you know the risk is reduced? … Slide 13: How Will You Reduce Risk of Recurrence? … Slide 16: How Will You Reduce Risk of Recurrence? … Slide 19: How Will You Know Risks Were Reduced? … Post the stories of reduced risks (with data!).
Share with others.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module2/module2-obtaining-organizational-buy-in-support.pptx
August 14, 2015 - At-risk behavior—Choosing to behave in a way that increases risk, where risk is not recognized or is … At-risk behavior is an active choice to engage in risky activity through a belief that the risk was either … to verify the system encourages healthy, risk-reducing behaviors. … To achieve optimal outcomes, organizations must design robust systems that minimize risks. … It is critical to reinforce behaviors that will reduce risk and deter behaviors that increase risk.
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-3/slides.html
September 01, 2017 - Slide 14: Fall Risk Assessment
Slide 15: Step 1: Fall Risk Screening/Assessment
Use a reliable … Add unit-level risk factors as needed. … Other risks:
IV pole.
Orthostatic hypotension.
Oxygen tubing. … Image: Paper labeled “fall risk.” … Choose a tool for assessing risk factors.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module3/module3_pu-bestpractices.docx
June 12, 2018 - up with a risk assessment score? … scores of the risk assessment tool, but also other factors placing the patient at risk. … ASK: How do you indicate your patients’ risk status? How is risk identified at shift handoff? … prevent pressure injuries is to create a care plan that is responsive to the patient’s pressure injury risks … this risk.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-01/magid-report.pdf
January 01, 2024 - Appropriate laboratory monitoring can reduce the risk of adverse events. … Prescribing Errors during Pregnancy
The use of medications during pregnancy has been recognized to pose risks … but benefits from use in pregnant women may be acceptable despite
the risk. … included (1) identifying and analyzing near-
misses and errors; (2) identifying and analyzing potential risks … high-risk drugs, and the elderly.
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ce.effectivehealthcare.ahrq.gov/talkingquality/explain/communicate/reason.html
November 01, 2018 - In general, advertisers and marketers believe that messages that emphasize risks people face are more … hospital information found that when quality information is framed in terms of helping people avoid risks … hospital, people understand it better, value it more, and are more willing to make tradeoffs to avoid risk … home data at all. [3]
These findings suggest that when people need to be reminded that there is a risk … because many people believe they all offer about the same quality of care and don’t think about the risks
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/fallpxoverview.pptx
October 01, 2017 - Does information exist to identify residents at risk?
How can this information be used? … preventing adverse events
Proactive rather than reactive
Identify residents with recent changes in risks … Profile risks for each resident in report
Prioritize residents for possible changes to their treatment … Worksheet
Each Self-Assessment worksheet is designed to help nursing home staff review how they:
Screen for risks … Mitigate those risks.
Prioritize residents who may need care plan changes.
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/implementation-guide/appendix-f.html
September 01, 2017 - (They are transitioning to risk-based assessment and interventions tied to risk. … Identified as a significant risk for falls.
Restraints.
Elopement risk. … once risk assessment has identified patient risk factors, care planning matches the identified risks. … plan addresses these risks. … Many of the patients are considered high risk based on risk assessment results.