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preventiveservices.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/measure-fall-rates.html
January 01, 2013 - Performance of care planning that addresses each risk factor identified during fall risk factor assessment … In some cases, the risk factors will vary depending on the hospital unit, so the risk factor assessment … For risk factor assessment to make a difference, all risk factors identified on the risk factor assessment … Ensure that the care plans address all areas of risk. … For each patient, determine the patient's identified risk factors.
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preventiveservices.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes2.html
August 01, 2022 - At-risk behavior—Choosing to behave in a way that increases risk, where risk is not recognized or is … At-risk behavior is an active choice to engage in risky activity through a belief that the risk was either … to verify the system encourages healthy, risk-reducing behaviors. … To achieve optimal outcomes, organizations must design robust systems that minimize risks. … It is critical to reinforce behaviors that will reduce risk and deter behaviors that increase risk.
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preventiveservices.ahrq.gov/hai/pfp/haccost2017-results.html
November 01, 2017 - For each HAC, we list the number of studies, the range of relative risk of death estimates from those … studies, our pooled meta-analysis relative risk estimate, underlying mortality in the population, and … 13
1.17–9.60
1.60 (1.38–1.87)
0.073
0.044 (0.028–0.064)
* No studies could be used in our relative … For example, one study that focused on Medicare beneficiaries and multiple drug classes reported a relative … Estimates of relative risk for mortality varied and included two studies showing protective effects for
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module3/module3_fall-prevention.docx
January 01, 2013 - Here are some other risks:
An IV pole could cause a patient to trip. … Slide 25
SAY: A risk score of 50 puts this patient at risk for a fall. … risks, such as mobility challenges, medications, mental status, and continence needs. … the patient and family (if possible), and key risks and interventions are checked on the paper tool shown … to have a dedicated care plan form within the medical record to help make staff aware of a patient’s risks
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preventiveservices.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/orthostatic-vital-sign.html
January 01, 2013 - When a patient is on a medication that may cause orthostasis and has other risk factors for falls. … Use this tool in conjunction with clinical assessment and a standard assessment of fall risk factors … (e.g., Tool 3H, "Morse Fall Scale for Identifying Fall Risk Factors," or Tool 3G, "STRATIFY Scale … for Identifying Fall Risk Factors" ) to determine a patient's risk factors for falls, and then plan care … A significant change in vital signs with a change in position also signals increased risk for falls.
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preventiveservices.ahrq.gov/news/newsletters/e-newsletter/899.html
February 01, 2024 - Home
News
Newsletter
AHRQ News Now
Heart Failure Patients’ Risk … Newsletter
AHRQ News Now
Events
Heart Failure Patients’ Risk … Heart Failure Patients’ Risk of Adverse Events Higher in Poor-Performing Hospitals
Patients with heart … hospitals with higher 30-day readmission rates and deaths from all causes have a 24 percent higher risk … failure admitted to hospitals that perform poorly on mortality and readmission measures have higher risk
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preventiveservices.ahrq.gov/patient-safety/settings/hospital/fall-tips/index.html
February 01, 2021 - This toolkit, developed through an AHRQ Patient Safety Learning Lab , consists of a formal risk … Being hospitalized puts patients at further risk for falls due to illness and the newness of the hospital … theoretical underpinning that fall prevention in hospitals is a three-step process: (1) assessing fall risk … evidence-based fall prevention intervention that uses bedside tools to communicate patient-specific risk … modalities provided access to real-time safety plans at the bedside, including patient-specific fall risk
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preventiveservices.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-3/guide.html
September 01, 2017 - Here are some other risks:
An IV pole could cause a patient to trip. … Slide 25
Say: A risk score of 50 puts this patient at risk for a fall. … risks, such as mobility challenges, medications, mental status, and continence needs. … the patient and family (if possible), and key risks and interventions are checked on the paper tool shown … to have a dedicated care plan form within the medical record to help make staff aware of a patient’s risks
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/antibiotic-prescribing-guide.docx
September 01, 2022 - However, all antibiotics, whether necessary or not, are associated with risks. … aortic dissections, seizures, and peripheral neuropathy—highlighting the importance of weighing the risks … The risk is highest when patients are actively receiving antibiotics, but this risk remains elevated … However, inappropriate antibiotic prescribing is a safety problem, and it exposes patients to unnecessary risks … : 7X risk – Fluoroquinolones: 5X risk • Risk is still elevated up to 12 weeks later 11
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preventiveservices.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/implementation.html
January 01, 2013 - patient's risk factors for falls to the admitting department. … Nurse:
Completes and documents fall risk assessments. … Reviews medications for fall risk and makes changes to medications as needed. … Fall risk factor report that summarizes which patients on the unit have specific risk factors. … First, consider how information about fall risks is conveyed in handing off patients to other units or
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preventiveservices.ahrq.gov/sites/default/files/publications2/files/hac-cost-report2017.pdf
November 01, 2017 - for the HAC with our pooled relative risk
estimate from the meta-analysis, using the formula: … In the above formula, RR indicates the pooled relative risk estimate from our meta-analysis, and Pr(D … We then calculated excess
mortality based on the estimated relative risk and the underlying mortality … For each HAC, we list the number of studies, the range
of relative risk of death estimates from those … Estimates of relative risk for mortality varied and
included two studies showing protective effects
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preventiveservices.ahrq.gov/health-literacy/professional-training/informed-choice/audio-script.html
September 01, 2020 - For example, many Americans have trouble understanding numerical expressions of risk. … Interrupting is OK if patient understanding is at risk. … “Every treatment has some risks. … Some goals may be long-term, such as reducing the risk of future injury or illness, or living as long … When there's a risk of harm rather than a virtual certainty, it can be challenging to explain.
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preventiveservices.ahrq.gov/evidencenow/projects/heart-health/evidence/smoking.html
March 01, 2021 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … Cigarette smoking accounts for one out of every five deaths and is estimated to increase the risk for … Smoking during pregnancy increases the risk of congenital anomalies, perinatal complications, miscarriage … Smoking Cessation in Primary Care
This facts-at-a-glance handout for clinicians summarizes evidence, risks … Ready or Not…Addressing Tobacco Use
This script and slide deck from a 14-minute presentation cover the risks
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module3/module3_slides_best-practices.pptx
June 16, 2017 - Fall Risk Assessment
‹#›
Step 1: Fall Risk Screening/Assessment
Use a reliable, prospectively … Other risks
IV pole
Orthostatic hypotension
Oxygen tubing
Clutter in the patient’s room
Vision problems … 25-45: Moderate risk
>45: High risk ______
* Weak gait: Short steps (may shuffle), stooped but able … 25-45: Moderate risk
>45: High risk 50
‹#›
Assessment of Risk Factors in Your Hospital
The questions … Identify key elements of a fall risk factor assessment.
Choose a tool for assessing risk factors.
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/factraining_slides.pptx
December 01, 2014 - Does information exist to identify residents at risk?
How can this information be used? … preventing adverse events
Proactive rather than reactive
Identify residents with recent changes in risks … Profile risks for each resident in report
Prioritize residents for possible changes to their treatment … Worksheet
Each Self-Assessment worksheet is designed to help nursing home staff review how they:
Screen for risks … associated with each of the On-Time program’s adverse events
Mitigate those risks
Prioritize residents
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preventiveservices.ahrq.gov/hai/cusp/modules/identify/index.html
July 01, 2018 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … identify recurring negative events in your system and apply CUSP and Sensemaking tools to help reduce the risk … What Will You Do to Reduce the Risk of Recurrence? (40 sec.) … How Will You Know the Risk is Reduced? (40 sec.)
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preventiveservices.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-3/slides.html
September 01, 2017 - Slide 14: Fall Risk Assessment
Slide 15: Step 1: Fall Risk Screening/Assessment
Use a reliable … Add unit-level risk factors as needed. … Other risks:
IV pole.
Orthostatic hypotension.
Oxygen tubing. … Image: Paper labeled “fall risk.” … Choose a tool for assessing risk factors.
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/ontime-preventablehospitaledvisits-overview.pptx
May 01, 2017 - Does information exist to identify residents at risk?
How can this information be used? … preventing adverse events
Proactive rather than reactive
Identify residents with recent changes
in risks … Profile risks for each resident in report
Prioritize residents for possible changes to their treatment … Worksheet
Each Self-Assessment Worksheet is designed to help nursing home staff review how they:
Screen for risks … Mitigate those risks.
Prioritize residents who may need care plan changes.
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preventiveservices.ahrq.gov/talkingquality/translate/scores/adjustment-scoring.html
January 01, 2023 - of the patient population, specifically whether—as a group—patients in one facility are at greater risk … Risk adjustment is a complex statistical enterprise. … [1] [2]
Why adjust for risks or severity? … Most common risk adjustments—for age, prior medical history, or comorbidities—are considered a good idea … Risk Adjustment for pediatric quality indicators.
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/diagnostic-toolkit/03-diagnostic-safety-infographic.pdf
August 01, 2021 - Improve
Diagnostic Safety strategy.
1- CRICO Strategies, 2014 Annual Benchmarking Report: Malpractice Risks … Medical Institutions; 2015. https://
www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-the-Diagnostic-Process … To Improve Diagnostic Safety
https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-the-Diagnostic-Process