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  1. 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.    
  2. 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
  3. 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
  4. 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
  5. 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
  6. 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
  7. 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
  8. 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
  9. 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
  10. 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
  11. 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
  12. 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.
  13. 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
  14. 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
  15. 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?
  16. 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 RiskRisk of Acute Asthma Associated With the Pediatric Use of Opioids. … Prescription Opioid Use Trajectories and Risk Factors Associated with Opioid-Related Hospitalizations
  17. 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.
  18. 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,
  19. 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
  20. 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

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