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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/module5_pressureinjury-msmt_slides.pptx
July 02, 2008 - At least one or two care processes, such as skin assessment and pressure injury risk assessment. … Ensure the known risk factors for pressure injuries are assessed. … Tool 5D
39
Assessment of Care Planning
All the risk factors identified in the pressure injury risk … Tailor your approach to each patient, based on the patient’s risk factors. … Pressure injury risk factor assessment is performed accurately within 24 hours of admission.
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talkingquality.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
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talkingquality.ahrq.gov/patient-safety/settings/index.html
July 01, 2023 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … Setting
AHRQ has developed a wealth of materials focused on a wide range of patient safety risks
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talkingquality.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
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talkingquality.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
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talkingquality.ahrq.gov/research/findings/final-reports/index.html?page=1
June 01, 2020 - Facility Design
(10)
Older Adults
(10)
Health Information Technology
(9)
Nursing Homes
(8)
Risk … R18 HS 023757 Topic(s): Medication Safety Publication Date: September 2019
Patient-Centric Risk … Publication Date: July 2019
Improving Safety After Hospitalization in Older Persons on High-Risk … Medication Safety Publication Date: July 2019
Developing a Patient-centered Model of the Risk … Grant Number: R01 HS 023800 Topic(s): Risk Assessment, Surgical Quality Improvement Publication Date
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talkingquality.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apd.html
August 01, 2022 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … CULTURE
Have leaders established methods to identify risks and provide employees opportunities to … FUTURE RISKS
Are there other areas in the organization where this could happen?
… FUTURE RISKS
Are there opportunities to improve trainings, competencies and orientation sessions
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talkingquality.ahrq.gov/evidencenow/projects/heart-health/about/cooperatives/nyc.html
March 01, 2021 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … need to help their patients adopt the ABCS of cardiovascular disease prevention: A spirin in high-risk … Heart disease is the primary cause of death in the city, and prevalence of cardiovascular disease (CVD) risk … support ABCS-driven care
Three expert webinars on topics related to evidence-based management of CVD risk … care practices [AcademyHealth, 2017]
Using Practice Facilitation in primary care settings to reduce risk
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talkingquality.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module1/mod1-slides.html
March 01, 2017 - Slide 18: Understanding Risk and Human Behavior 1
Human Error:
Inadvertently completing the wrong … At-Risk Behavior:
Choosing to behave in a way that increases risk where risk is not recognized, or … Reckless Behavior:
Choosing to consciously disregard a substantial and unjustifiable risk.
1. … Slide 19: Managing Error and Risk 1
Human Error
At-Risk Behavior
Reckless Behavior … believed insignificant or justified
Manage through:
Removal of incentives for at-risk behaviors
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talkingquality.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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talkingquality.ahrq.gov/patient-safety/patients-families/index.html
June 01, 2023 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … 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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talkingquality.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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talkingquality.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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talkingquality.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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talkingquality.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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talkingquality.ahrq.gov/opioids/health-systems-research.html
July 01, 2021 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … 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
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talkingquality.ahrq.gov/news/newsroom/case-studies/201801.html
April 01, 2018 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … Chris Myers, R.N., B.S.N., the hospital’s risk manager and patient safety officer, explained that use … Myers said AHRQ’s program emphasizes the importance of accurately assessing the risk of falls for patients … “There had been some confusion as to whether identifying patients as ‘low fall risk’ was actually the … most accurate risk level for most patients,” he explained.
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talkingquality.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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talkingquality.ahrq.gov/research/findings/studies/index.html?page=480
January 01, 2024 - (146)
Rehabilitation
(61)
Research Methodologies
(417)
Respiratory Conditions
(366)
Risk … , Implementation
Moga DC , Carnahan RM , Lund BC Risks and benefits of bladder antimuscarinics … This study evaluated the risks and benefits of drugs to reduce urinary incontinence that were used by … Risks and benefits of bladder antimuscarinics among elderly residents of Veterans Affairs Community Living … months during an eight and a half-year study, researchers found that symptom burden is an independent risk
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talkingquality.ahrq.gov/research/findings/studies/index.html?page=481
January 01, 2024 - (146)
Rehabilitation
(61)
Research Methodologies
(418)
Respiratory Conditions
(367)
Risk … , Implementation
Moga DC , Carnahan RM , Lund BC Risks and benefits of bladder antimuscarinics … This study evaluated the risks and benefits of drugs to reduce urinary incontinence that were used by … Risks and benefits of bladder antimuscarinics among elderly residents of Veterans Affairs Community Living … months during an eight and a half-year study, researchers found that symptom burden is an independent risk