-
pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/candor-acknowledgments.pdf
September 14, 2017 - Boothman, J.D., Executive Director, Clinical Safety and Chief Risk Officer,
University of Michigan Health … ARM, formerly with the University of Illinois-Chicago and
now Director, Office of Patient Safety and Risk … Scott, Ph.D., R.N., Manager of Patient Safety and Risk Management, University of
Missouri
- Kelly … Driver, J.D., M.B.A., CEO of The Risk Authority Stanford and Chief Risk Officer of
Stanford Health … Hickson, M.D., Senior Vice President for Quality, Safety and Risk Prevention,
Assistant Vice Chancellor
-
pbrn.ahrq.gov/opioids/health-systems-research.html
July 01, 2021 - approaches to improve the use of screening for unhealthy alcohol use, brief intervention for those at risk … opioids and other substance use disorders
Toward Safer Opioid Prescribing for Chronic Pain in High Risk … Risk of Acute Asthma Associated With the Pediatric Use of Opioids. … Prescription Opioid Use Trajectories and Risk Factors Associated with Opioid-Related Hospitalizations
-
pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/tool_safe-mgso4.docx
May 30, 2013 - of transition communication techniques assures a shared mental model of plan of care and perceived
risks … Family Engagement (CUSP)
Key Perinatal Safety Elements
Examples/customizable components
Discuss risks … Use unit-established process for conveying risks and benefits of magnesium sulfate use to patient and … Magnesium sulphate for women at risk of preterm birth for neuroprotection of the fetus. … Patient comfort and education
· Discuss risks and benefits of magnesium sulfate with patient and family
-
pbrn.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/medication/safe-medication-slides.html
July 01, 2023 - Slide 4: High-Alert Medications 1
High-alert medications are "drugs that bear a heightened risk of … 4,5 , 6,7
Use of a uniform mixed preparation unitwide for all patients to reduce variability and risk … Ensures a shared mental model of plan of care and perceived risks—
Between shifts. … Slide 16: Key Safety Elements: Patient and Family Engagement
Discuss risks and benefits of oxytocin … Slide 27: Key Safety Elements: Patient and Family Engagement
Discuss risks and benefits of intrapartum
-
pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apc.html
August 01, 2022 - Comments
Leadership and Culture
Are governance/senior leaders regularly and thoroughly briefed on risks … 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?
-
pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module5/module5_tools.docx
August 03, 2017 - Medication affecting risk of falls
Sedative and psychotropic medication, or medication with drowsiness … ”*:
Number of higher risk patients:
8
Chart: full medication review requested? … For any of the 20 patients who are “higher risk”*:
Number of higher risk patients:
Chart: full medication … * In some wards all patients are counted as high risk, for other wards only some. … Completion Date for Plan
Fall risk factor assessment is performed within 24 hours of admission
-
pbrn.ahrq.gov/hai/cusp/videos/index.html
September 01, 2019 - and Independent Input Identify Your Unit's Safety Issues Develop a Plan of Action How Will You Know Risk … Identifying Contributing Factors What Will You Do to Reduce the Risk of Recurrence?
-
pbrn.ahrq.gov/evidencenow/heart-health/cholesterol/statins.html
September 01, 2018 - University reviews current recommendations for the use of statins in lowering cholesterol and reducing CVD risk
-
pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/module5_pu_measurement.docx
January 01, 2016 - Performance of care planning that addresses each risk factor identified during risk factor assessment … Slide 38
SAY: Risk assessment is the cornerstone of prevention. … Calculate the percentage of patients who have a completed risk score. … Slide 40
SAY: For a risk factor assessment to make a difference, all the risk factors identified in … Ensure that the care plan addresses all areas of risk.
-
pbrn.ahrq.gov/sites/default/files/wysiwyg/evidencenow/building-capacity/EvidenceNOW-BSC-AL-profile.pdf
September 01, 2021 - Consortium for Southeast
Healthcare Quality
Project Period:
2021-2023
Supporting cardiovascular risk … improvement (QI) capacity and improve cardiovascular health through
implementation of evidence-based, risk … The project seeks to
coordinate cardiovascular risk reduction efforts across the state to create efficiency … care practices and non-traditional
providers of primary care across the state in a Cardiovascular
Risk … The evaluation will assess the creation and utility
of the Cardiovascular Risk Reduction Network of
-
pbrn.ahrq.gov/patient-safety/patients-families/index.html
June 01, 2023 - five-step process for shared decisionmaking that includes exploring and comparing the benefits, harms, and risks … The Toolkit to Engage High-Risk Patients in Safe Transitions Across Ambulatory Settings
This toolkit … Research Summaries for Consumers
These free research summaries discuss the benefits and risks of different
-
pbrn.ahrq.gov/patient-safety/settings/ambulatory/index.html
July 01, 2022 - It is a customizable "train the trainer" program plus specialized tools to reduce risks to patient safety … Toolkit to Engage High-Risk Patients in Safe Transitions Across Ambulatory Settings is designed to help
-
pbrn.ahrq.gov/funding/grantee-profiles/grtprofile-chui.html
March 01, 2022 - Chui hypothesized that making older adults aware of high-risk OTC medications would facilitate their … evaluate this intervention in 63 AAH pharmacies to enhance patients’ awareness of and attention to risks
-
pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/psml-planning-grants-final-report.pdf
May 01, 2016 - Risk can be minimized with solutions
that integrate medication risk management efforts into transitional … risk management efforts into
transitional care models. … to enhance
communication between patients and families and their care providers, thus reducing the risks … Modeling Risk and Reducing Liability Through Better
Communication and Teamwork. … examined, 78 percent involved an
element of informed consent or SDM, primarily in the areas of treatment risks
-
pbrn.ahrq.gov/research/findings/final-reports/index.html
June 01, 2023 - Facility Design
(10)
Older Adults
(10)
Health Information Technology
(9)
Nursing Homes
(8)
Risk … Planning, Nursing Homes Publication Date: August 2022
Prescription Opioid Use Trajectories and Risk … Tools Publication Date: July 2021
Toward Safer Opioid Prescribing for Chronic Pain in High Risk … Grant Number: R01 HS 025402 04 Topic(s): Medication Safety Publication Date: April 2021
Risk
-
pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
August 01, 2022 - Individual is not educated about potential risk and sees no value in established policies to prevent … Manage by:
Removing incentives for at-risk behaviors. … Educate about potential risks.
Redesign of system factors. … Risk management. … J Healthc Risk Manag. 2013;33(2):11-20.
What are the Outputs from the Solutions Meeting?
-
pbrn.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/root-cause.html
January 01, 2013 - conjunction with a medical provider's or pharmacist's assessment of medications contributing to fall risk … (go to Tool 3I, "Medication Fall Risk Score and Evaluation Tools" ) and a medical provider's assessment … separate tool ( Tool 3N, Postfall Assessment, Clinical Review ) covers how to assess and follow injury risk
-
pbrn.ahrq.gov/patient-safety/resources/learning-lab/ehrll-long-desc.html
April 01, 2022 - highly reliable systems that address communication and coordination challenges that pose patient safety risks … Lessons learned suggest future work should involve multidisciplinary teams, risk-based stratification … clinical pathway can reduce the deep surgical site infection rate after posterior spinal fusion in high-risk … Risk factors for increased blood loss during spinal fusion for children with neuromuscular scoliosis
-
pbrn.ahrq.gov/talkingquality/measures/types.html
July 01, 2015 - Risk-adjustment methods—mathematical models that correct for differing characteristics within a population … However, the science of risk adjustment is still evolving. … Experts acknowledge that better risk-adjustment methods are needed to minimize the reporting of misleading
-
pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool13_ed_care_plan.docx
May 01, 2015 - Department, Hospital Medicine, Social Work, Case Management, Behavioral Health, Palliative Care, Quality, Risk … Name: ____________________ Phone/Email: _____________________________
ED Care Plan Example 1
High-Risk … high potential for abuse]
· [Medical ethics do not require prescribing a medication when you judge the risks … findings
· 2 Chest CT Jan, Feb 2015, unremarkable
· Stress Thallium Mar 2015, normal
For Help With High-Risk … [date plan was created and/or last updated]
Reason for Care Plan:
· [short phrase to describe high risk