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pcmh.ahrq.gov/innovations/index.html
August 01, 2021 - topics in this section
Innovations
Downloadable Databases
Connecting Those at Risk … Connecting Those at Risk to Care: The Quick Start Guide to Developing Community Care Coordination Pathways … Pathways Community HUB Manual: A Guide to Identify and Address Risk Factors, Reduce Costs, and Improve
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/tool_safe-oxytocin.docx
May 01, 2017 - of error.12
· The risks and benefits of low- versus. high-dose oxytocin protocols remain an active … The use of standard NICHD nomenclature17,18,19 reduces confusion and risk of error. … · Use unit-established process for conveying risks and benefits of oxytocin use to patient and family … Verifying and documenting indications for use (continued)
discussion with patient of risks and benefits … and documentation of the discussion about risks, benefits, and alternatives should be documented to
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pcmh.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/communication/strategy6i-shared-decisionmaking.html
April 01, 2023 - These tools increase knowledge, improve risk estimates, increase patient's involvement in decisions, … benefited from an increased level of understanding that allowed discussions to focus on the critical risk … key to success lies in training physicians and other members of the care team to:
Communicate about risks … expressed needs when making recommendations for care. 18
Clinical decision support tools, such as risk … can follow-up with patients to determine whether they understood that they had options, how much the risks
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pcmh.ahrq.gov/health-literacy/publications/ten-attributes.html
January 01, 2024 - Addresses health literacy in high-risk situations, including care transitions and communications about … The AHRQ Academy Playbook on Integrating Behavioral Health in Primary Care
Toolkit to Engage High-Risk … Addresses health literacy in high-risk situations, including care transitions and communications about … High-risk decisions, situations, and transitions demand more attention to health literacy. … Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation: High-Risk
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/lepslhandouts.pdf
July 25, 2012 - for
Patients With
Limited English Proficiency
Overview/Objectives
Understand the safety risk … teen
$71 million lawsuit
2 TeamSTEPPS LEP Patient Safety | Essentials
Essentials
High-Risk … Surgery
Transitions in care, including intake and discharge
Medication reconciliation
Added Risk … history
Latex allergy almost missed before surgery
“Opportunity” Scenario
What are the risks
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pcmh.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/postfall-assessment.html
January 01, 2013 - Word Version [ - 33.64 KB]
Background: This protocol explains how to assess and follow injury risk … Postfall Assessment, Clinical Review
Note: There is increased risk of intracranial hemorrhage in patients … medical record, document the incident, outcome, and initial and ongoing observations, and update fall risk
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pcmh.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/overview.html
January 01, 2013 - Fall prevention involves managing a patient's underlying fall risk factors (e.g., problems with walking … fall prevention care are highly routinized; other aspects must be tailored to each patient's specific risk … Joint Commission standards require ongoing efforts to assess risk for falls and to intervene to reduce … fall risk; staff education regarding fall prevention; and an evaluation of the effectiveness of the … hospital's fall prevention strategies, including fall risk assessment, interventions, and education.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/mcc-summit/mcc-summit-arlene.pdf
November 17, 2020 - • Common, Costly
• Health equity issue
• Health system ill-designed to meet the needs of
those at risk … • Prevention interventions targeted at reducing the
prevalence of common chronic disease risk factors … with
a particular focus on interventions to reduce the
likelihood those “at risk” will go on to develop … MCC
• Targeted interventions to improve health and reduce the
risk of adverse events and complications … issues
• Targeted interventions for those who have complex
management issues and who are at “high risk
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module3/mod03-gap-analysis-guide.pdf
April 01, 2016 - Are governance/senior leaders regularly and thoroughly briefed on risks and hazards?
b. … Are patient safety risks, hazards, and opportunities discussed and documented at board meetings?
f. … 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? … There is strong consensus that
improved communication between providers and patients about risks to
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pcmh.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety-fac-guide.html
July 01, 2023 - When Possible
Say:
The preoperative briefing reviews the plan ahead for patient care and the risks … Risk assessments may include the presence of clinical conditions that increase risk of hemorrhage, or … 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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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - Recommended Practice: Assess risk factors
• Determine which pediatric patients are at increased risk … o High-risk surgery (e.g., emergent and prolonged procedures, open vs. laparoscopic). … • Use nasogastric tubes selectively since they can increase the risk of aspiration. … Development and validation of a risk calculator
predicting postoperative respiratory failure. … Postoperative pulmonary complications: an update on risk assessment and
reduction.
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pcmh.ahrq.gov/news/blog/ahrqviews/achieve-health-equity.html
August 01, 2021 - issues such as hypertension, obesity, and diabetes, they were significantly more vulnerable to the risks … important ground by exploring how differences in job characteristics and household composition impacted risks … In contrast, workers in office-based jobs who are able to work remotely have a significantly lower risk
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module3/module3_tools.docx
January 01, 2012 - 1 = Moderate risk
2 or above = High risk
3H: Morse Fall Scale for Identifying Fall Risk Factors … 25-45: Moderate risk
>45: High risk
______
* Weak gait: Short steps (may shuffle), stooped but able … calculated by (risk level score) x (number of medications in that risk level category). … Fall Scale for Identifying Fall Risk Factors,” or 3G, “STRATIFY Scale for Identifying Fall Risk Factors … medication-related risk for falls.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module4/putoolkit_module4_tools.docx
January 01, 1995 - Hot water and soap may dry the skin and increase the risk for pressure ulcers.
5. … A low Braden score is associated with increased pressure ulcer risk.
44. … Hot water and soap may dry the skin and increase the risk for pressure ulcers.
True
5. … A low Braden score is associated with increased pressure ulcer risk.
True
44. … Does the education provided address risk assessment tools and procedures?
7.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/patient-safety/rev-reportaddendum.pdf
March 01, 2021 - Routinely assessing patient risk during this period is critical to facilitate tailoring
appropriate … If left
unaddressed, behavioral health and social needs are key risk factors for postdischarge adverse … Consider
using a pharmacist for complex medication regimens or high-risk patients. … • Advise high-risk patients to let the primary care practice know if they are thinking about
going … Risk
stratification may help practices more efficiently allocate resources to high-risk patient groups
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4p_combo_pdi02-pressureulcer-bestpractices.pdf
January 01, 2012 - equipment
and devices.1
• Pressure ulcer rates are high in children, particularly those with high-risk … from 2.4 to 7.7 per 1,000
pediatric discharges (across all children).2-4 In subgroups at particular risk … (3.5 times the odds of children without the complication), even after
adjusting for numerous other risk … documentation record for the completion of a
total skin assessment and risk assessment.11,12 … Risk assessment & prevention of
pressure ulcers 2011 supplement. Toronto, ON: RNAO; 2011.
11.
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pcmh.ahrq.gov/npsd/data/dashboard/index.html
October 01, 2023 - Pressure Ulcer Dashboard
Details the documentation of increased risk for pressure ulcer following a … risk assessment; and the timing of the first risk assessment for reported pressure ulcers or sDTIs. … new analyses by age, deeper explorations of common activities prior to fall, and enhanced analyses of risk … falls, as well as the ability to filter by fall assistance and use of medication known to increase risk
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pcmh.ahrq.gov/funding/grantee-profiles/grtprofile-dalal.html
January 01, 2024 - Dalal received a 5-year AHRQ grant to create a digital health app that predicts the risk of post-discharge … noted that “clinically-integrated digital health apps have the potential to more accurately predict risk … It also will help patients to understand their individualized risks of adverse events during care transitions
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pcmh.ahrq.gov/patients-consumers/patient-involvement/index.html
November 01, 2016 - Patients and families who engage with health care providers ask good questions and help reduce the risk
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety_facguide.docx
May 01, 2017 - Checklists help to facilitate safety in high-complexity, high-risk, and high-reliability professions … sections
Slide 9
SAY:
The preoperative briefing reviews the plan ahead for patient care and the risks … .18-21
· Individual risk factors predict some occurrences of obstetric hemorrhage.
· Risk assessments … 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