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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/safemed_facguide.docx
May 01, 2017 - To reduce the risk of errors, these medications require special safeguards such as the following:
Improving … The key safety elements are the following:
Discussing risks and benefits of oxytocin use for labor induction … Using the maintenance infusion to administer a bolus manually is a high-risk practice that should be … Using transition communication techniques to ensure a shared mental model of plan of care and perceived risks … The key safety elements are the following:
Having unit-established processes for conveying risks and
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pbrn.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module1/mod1-facguide.html
March 01, 2017 - Slide 18: Understanding Risk and Human Behavior 1
Say:
Just Culture helps us understand risk and … At-risk behavior—Choosing to behave in a way that increases risk, where risk is not recognized or is … Slide 19: Managing Error and Risk 1
Say:
To improve outcomes, human error, at-risk behavior, and … At-risk behavior is an active choice to engage in risky activity through a belief that the risk was either … for healthy, risk-reducing choices.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module5/module5_slides_fallprev.pptx
December 03, 2012 - Performance of care planning that addresses each risk factor identified during fall risk factor assessment … Ensure that known risk factors for falls are assessed. … Page 78
‹#›
Care Planning Assessment
All risk factors identified on the fall risk factor assessment … that care plans address all areas of risk.
‹#›
Assessment of Care Plan Performance
See the sample … A care plan addressing every deficit on the fall risk factor assessment has been developed and is being
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pbrn.ahrq.gov/patient-safety/settings/index.html
July 01, 2023 - Setting
AHRQ has developed a wealth of materials focused on a wide range of patient safety risks
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety_facguide.pdf
May 01, 2017 - Unit Safety 6
SAY:
The preoperative briefing reviews the plan
ahead for patient care and the risks … o Risk assessments may include the
presence of clinical conditions that
increase risk of hemorrhage … o Risk assessment can then
determine the unit’s process for
patients based on level of risk, for
example … These include—
• Having situational awareness about
maternal and fetal risks and status. … during transitions of
care helps to assure a shared mental
model of the plan of care and
perceived risks
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pbrn.ahrq.gov/news/newsroom/case-studies/201801.html
April 01, 2018 - Chris Myers, R.N., B.S.N., the hospital’s risk manager and patient safety officer, explained that use … Myers said AHRQ’s program emphasizes the importance of accurately assessing the risk of falls for patients … “There had been some confusion as to whether identifying patients as ‘low fall risk’ was actually the … most accurate risk level for most patients,” he explained.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/prp/prp-wound-care.pdf
September 17, 2020 - autologous PRP demonstrated a statistically
significant increase in complete wound closure or healing (Relative … We extracted or calculated relative risk
(RR) and corresponding 95 percent confidence intervals for … or unclear risk of bias. … small (<300) or the confidence intervals included substantial benefits and harms
(defined as 0.25 relative … risk reduction or increase).
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pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apd.html
August 01, 2022 - CULTURE
Have leaders established methods to identify risks and provide employees opportunities to … FUTURE RISKS
Are there other areas in the organization where this could happen?
… FUTURE RISKS
Are there opportunities to improve trainings, competencies and orientation sessions
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pbrn.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module1/mod1-slides.html
March 01, 2017 - Slide 18: Understanding Risk and Human Behavior 1
Human Error:
Inadvertently completing the wrong … At-Risk Behavior:
Choosing to behave in a way that increases risk where risk is not recognized, or … Reckless Behavior:
Choosing to consciously disregard a substantial and unjustifiable risk.
1. … Slide 19: Managing Error and Risk 1
Human Error
At-Risk Behavior
Reckless Behavior … believed insignificant or justified
Manage through:
Removal of incentives for at-risk behaviors
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pbrn.ahrq.gov/health-literacy/professional-training/shared-decision/workshop/mod2-slides.html
September 01, 2020 - Know the benefits and risks of each option
Understand how they relate to your patient's situation and … Help you convey the evidence-based treatment options and how they compare in benefits and risks to your … Compare treatment options—risks and benefits.
Questions to ask provider. … Help clarify patients' preferences for risks and benefits of options. … Improves accurate risk perceptions of possible benefits and harms among patients.
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pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apb.html
August 01, 2022 - Leadership and Culture:
Are governance/senior leaders regularly and thoroughly briefed on risks and … Are patient safety risks, hazards, and opportunities discussed and documented at board meetings? … Is a risk manager available at all times to respond to patient safety incidents?
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pbrn.ahrq.gov/evidencenow/projects/heart-health/about/cooperatives/nyc.html
March 01, 2021 - need to help their patients adopt the ABCS of cardiovascular disease prevention: A spirin in high-risk … Heart disease is the primary cause of death in the city, and prevalence of cardiovascular disease (CVD) risk … support ABCS-driven care
Three expert webinars on topics related to evidence-based management of CVD risk … care practices [AcademyHealth, 2017]
Using Practice Facilitation in primary care settings to reduce risk … Medicine, Population Health Summit, 2016]
Using Practice Facilitation in primary care settings to reduce risk
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module3/putoolkit_module3_tools.docx
August 31, 2017 - Generally, a score of 18 or less indicates at-risk status. … factors and 1-3 for the last risk factor. … Generally, a score of 14 or less indicates at-risk status. … Use: Individualize the care plan to address the needs of at-risk patients. … PRESSURE ULCER RISK ASSESSMENT CASE STUDY
Mr.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/evidencenow/building-capacity/EvidenceNOW-BSC-TN-profile.pdf
September 01, 2021 - tobacco use, sixth for diabetes, 12th for obesity rates, and fourth for physical
inactivity — all potent risk … Largely as a
consequence of these risk factors, Tennessee ranks third highest in the nation in
rates … health with a focus on hypertension control and smoking cessation — two
of the most prevalent CVD risk … factors in Tennessee — to reduce and/or eliminate
disparities and inequities in CVD outcomes and risks
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pbrn.ahrq.gov/evidencenow/heart-health/aspirin/pcor.html
August 01, 2018 - patient-centered outcomes research (PCOR) findings and guidelines for aspirin use in people at high risk
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module2/putoolkit_module2_tools.docx
February 16, 2011 - Specification of appropriate pressure ulcer risk and monitoring tools
c. … if your facility has a process to screen patients for pressure ulcer risk. … Do you use either the Norton or Braden pressure ulcer risk assessment tool?
If Yes, STOP. … Decide which scale will be used for performing risk assessment. … Determine who will complete the daily skin and risk assessments. Tool 4A.
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pbrn.ahrq.gov/talkingquality/measures/understand/patient-comments.html
February 01, 2016 - J Risk Uncertain 1997;14(3):235–57. [4] Schwartz LM, Woloshin S, Black WC, Welch HG. … What does it mean to understand a risk? Evaluating risk comprehension. … Risk as feelings. Psychol Bull 2001 Mar;127(2):267-86. [7] Redelmeier DA, Rozin P, Kahneman D.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/medread-tools.pdf
July 28, 2016 - Care Planning
This tool provides
discharge planners with a
set of prompts to identify
readmission risks … and to take
steps to ensure those risks are
addressed in the transitional
Day-to-day readmission … Description
This tool provides discharge planners with a set of prompts to identify readmission risks … and to
take steps to ensure those risks are addressed in the transitional care (discharge) plan. … Accessed July 28, 2016.
2
WHOLE-PERSON CARE TRANSITIONAL PLANNING TOOL
Readmission Risks and
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/module5_pressureinjury-msmt_slides.pptx
July 02, 2008 - At least one or two care processes, such as skin assessment and pressure injury risk assessment. … Ensure the known risk factors for pressure injuries are assessed. … Tool 5D
39
Assessment of Care Planning
All the risk factors identified in the pressure injury risk … Tailor your approach to each patient, based on the patient’s risk factors. … Pressure injury risk factor assessment is performed accurately within 24 hours of admission.
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pbrn.ahrq.gov/evidencenow/heart-health/cholesterol/control.html
September 01, 2018 - cholesterol levels and diet and exercise guidelines for lowering cholesterol levels and heart disease risk