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pbrn.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/about.html
July 01, 2023 - In addition to communication failures, patients on labor and delivery (L&D) units are at risk of medication … use of inappropriate interventions, or interventions provided in an unsafe manner, also increases the risk
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b2a_combo_ratesgenbysas.pdf
March 01, 2016 - Note: The current version of the AHRQ QI software does not have risk-adjustment capabilities
when using … However, this tool includes information about risk adjustment that will
be relevant when looking at … Identify populations at risk.
3. Calculate observed (raw) indicator rates.
4. … Risk adjust the indicator rates (where applicable).
5. … SAS*
PSI_PROVIDER_2
.SAS*
PDI_PROVIDER_2
.SAS*
Calculates expected rates, risk-
adjusted rates,
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pbrn.ahrq.gov/patient-safety/settings/hospital/fall-prevention/webinar/slides.html
June 01, 2018 - Slide 18
Challenge
Inadequate Risk Assessments and Reassessments
Image of young man with clipboard … and image of rubber stamp
Slide 19
Opportunity
Accurate and effective risk assessments
Employing … critical thinking and clinical judgment
Consistency in approach
Identifying and communicating risk … possible time
Slide 20
Tools
Morse Fall Scale (3H)
STRATIFY Scale (3G)
Medication Fall Risk … target education to address gaps in staff knowledge
Environmental safety
Medications associated with risk
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pbrn.ahrq.gov/hai/cusp/modules/apply/index.html
July 01, 2018 - Toolkit introduces Just Culture principles, which emphasize shared accountability and attitudes towards risk
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pbrn.ahrq.gov/evidencenow/heart-health/smoking/pcor.html
August 01, 2018 - Resource description: This EvidenceNOW fact sheet provides an overview of PCOR findings about the risks
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pbrn.ahrq.gov/news/newsroom/press-releases/data-highlight-inequities.html
March 01, 2021 - And according to the third vaccine distribution scenario studied, prioritizing adults at increased risk … However, this would delay eligibility for some workers who have increased risk of exposure and increased … risk of transmission to others, the AHRQ researchers found.
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pbrn.ahrq.gov/tools-and-resources/pbrn-literature/building-equity-improvement-quality-improvement-reducing
January 02, 2022 - Patients identified by algorithm as high risk for non-completion entered into intensive patient navigation … patient, Patients, population, Population Health, Public Health, quality, quality improvement, Research, Risk
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pbrn.ahrq.gov/tools-and-resources/pbrn-literature/monitoring-suicidal-patients-primary-care-using-electronic
January 01, 2022 - Abstract: INTRODUCTION: Patients at risk for suicide often come into contact with primary care providers … Pharmacy, Physicians, primary care, provider, Public Health, Record, Records, Research, Research Support, Risk
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pbrn.ahrq.gov/teamstepps-program/welcome-guides/administrators.html
July 01, 2023 - TeamSTEPPS 3.0 tools and concepts can help you equip teams in your organization to better understand these risks … The expanded functionalities available in electronic health records risk an overdependence on technologies … all these factors contribute to fatigue and burnout that create additional challenges for teams and risks
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pbrn.ahrq.gov/teamstepps-program/welcome-guides/frontline-providers.html
July 01, 2023 - TeamSTEPPS 3.0 tools and concepts can help you to better understand these risks and how to constructively … The expanded functionalities available in electronic health records risk an overdependence on technologies … all these factors contribute to fatigue and burnout that create additional challenges for teams and risks
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/safemed_facguide.pdf
May 01, 2017 - To
reduce the risk of errors, these medications
require special safeguards such as the
following: … The key safety elements are the following:
• Discussing risks and benefits of
oxytocin use for labor … Using the maintenance
infusion to administer a bolus
manually is a high-risk practice that
should … 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
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pbrn.ahrq.gov/patient-safety/resources/learning-lab/building-ambulatory-long-desc.html
April 01, 2021 - needs-driven technical and culture-based solution for subcritical test results, management of high-risk … professionals to actively track subcritical test results (e.g., pulmonary nodules) and monitor high-risk … electronic registry for urology clinic staff to monitor men on active surveillance for prostate cancer risk … jirovecii pneumonia (PJP) prophylaxis patterns among patients with rheumatic diseases receiving high-risk … a novel method to develop context-sensitive interventions to reduce quality gaps in monitoring high-risk
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pbrn.ahrq.gov/sites/default/files/publications/files/universalicu.pdf
September 01, 2013 - The benefits and potential risks should be weighed with any strategy. … of infection during the high-risk period
of critical care. … Goal is to prevent MRSA during high-risk periods (ICU stays, post-op). … Product Safety and Adverse Events
Chlorhexidine (CHG) Risk
The risks associated with the use … Nasal Mupirocin Risk
The risks associated with use of nasal mupirocin include mild side effects of
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_safe-csection.docx
May 01, 2017 - Examples
Preoperative briefing
· The briefing reviews the plan ahead for patient care and the risks … It includes reviewing patient information, procedure, indications, risk, medical history, fetal status … Discovery form
· Root cause analysis
· Eindhoven model
· Failure mode and effects analysis
· Probabilistic risk … of transition communication techniques assures a shared mental model of plan of care and perceived risks … Patient and Family Engagement (CUSP Module)
Key Perinatal Safety Elements
Examples
Communicate risks
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pbrn.ahrq.gov/ncepcr/research/health-literacy.html
September 01, 2022 - step process for shared decision making that includes exploring and comparing the benefits, harms, and risks
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pbrn.ahrq.gov/news/newsletters/e-newsletter/876.html
August 01, 2023 - monitoring, also based on the systematic review, found postpartum home monitoring significantly reduced the risk … Implementation of suicide risk estimation analytics to support mental health care for quality improvement … Factors associated with lung cancer risk factor documentation. … Adapting an electronic STI risk assessment program for use in pediatric primary care.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module4/module4_pu-implementation_slides.pptx
November 20, 2014 - Conducting pressure injury risk
assessments.
Planning care for risk prevention. … Unit staff tell the Wound Care Team about high-risk patients or if skin problems occur. … Page 65
23
Electronic Health Record Opportunities
What information about pressure injury risk factors … logical place in the record to collect, organize, and assess information about patient pressure injury risk … plan/documentation
Staff Education: RN, CEO, CNO, PCT
2-hour didactic competency training:
Braden risk
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pbrn.ahrq.gov/sites/default/files/docs/Engaging-Patients-Presentation-020615.pdf
January 05, 2015 - physician on values
and preferences
• Provider gives
treatment options and
the benefits and risks … the illness and
its treatment
Provider gives all
relevant disease
information:
benefits and risks
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pbrn.ahrq.gov/evidencenow/heart-health/aspirin/stroke.html
September 01, 2018 - description: This patient education booklet explains how heart attack and stroke happen, and the potential risks
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pbrn.ahrq.gov/evidencenow/heart-health/smoking/detailing.html
August 01, 2018 - Primary Care
Resource description: This facts-at-a-glance handout for clinicians summarizes evidence, risks