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pcmh.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?
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pcmh.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
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pcmh.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?
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pcmh.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
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pcmh.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.
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pcmh.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
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pcmh.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
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pcmh.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
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pcmh.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
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pcmh.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
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pcmh.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
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pcmh.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?
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pcmh.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
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pcmh.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
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pcmh.ahrq.gov/page/medical-home-what-do-we-know-what-do-we-need-know-review-earliest-evidence-effectiveness-of-the-patient-centered-medical-home-model-table-10
March 01, 2013 - Geriatric Resources for Assessment and Care of Elders b Year 2 : Reduced number of stays by 44% among high-risk … (high PRA score) patients Year 3 : Number of stays among all patients and high-risk (high PRA score … ) patients Year 1 : Number of stays among all patients and high-risk (high PRA score) patients Year
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pcmh.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
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pcmh.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
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pcmh.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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pcmh.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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pcmh.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