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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
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/safemed_facguide.pdf
May 01, 2017 - To
reduce the risk of errors, these medications
require special safeguards such as the
following: … The key safety elements are the following:
• Discussing risks and benefits of
oxytocin use for labor … Using the maintenance
infusion to administer a bolus
manually is a high-risk practice that
should … transition communication
techniques to ensure a shared
mental model of plan of care and
perceived risks … The key safety elements are the following:
• Having unit-established processes
for conveying risks
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talkingquality.ahrq.gov/health-literacy/professional-training/shared-decision/tool/resource-1.html
September 01, 2020 - 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 … Clearly communicate the risks and benefits of each option. … The provider presents the options, describes the risks and benefits of each, and explores the patient's
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talkingquality.ahrq.gov/patient-safety/reports/engage/interventions/medmanage.html
June 01, 2023 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … These tools will also help to identify patient behaviors that may be putting patients at risk for an
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talkingquality.ahrq.gov/research/findings/final-reports/index.html?page=0
June 01, 2023 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … Planning
(7)
Nursing Homes
(7)
Patient Safety Measure Development and Implementation
(7)
Risk … Planning, Nursing Homes Publication Date: August 2022
Prescription Opioid Use Trajectories and Risk … Safety Publication Date: August 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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talkingquality.ahrq.gov/research/findings/final-reports/index.html
June 01, 2023 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … 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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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_safe-csection.docx
May 01, 2017 - Examples
Preoperative briefing
· The briefing reviews the plan ahead for patient care and the risks … It includes reviewing patient information, procedure, indications, risk, medical history, fetal status … Discovery form
· Root cause analysis
· Eindhoven model
· Failure mode and effects analysis
· Probabilistic risk … of transition communication techniques assures a shared mental model of plan of care and perceived risks … Patient and Family Engagement (CUSP Module)
Key Perinatal Safety Elements
Examples
Communicate risks
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talkingquality.ahrq.gov/evidencenow/projects/heart-health/about/stories/in-action/oklahoma.html
March 01, 2021 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … Progress under EvidenceNOW included:
Increasing blood pressure measurement for patients at risk of
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talkingquality.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apb.html
August 01, 2022 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … Leadership and Culture:
Are governance/senior leaders regularly and thoroughly briefed on risks and … 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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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module4/module4_pu-implementation_slides.pptx
November 20, 2014 - Conducting pressure injury risk
assessments.
Planning care for risk prevention. … Unit staff tell the Wound Care Team about high-risk patients or if skin problems occur. … Page 65
23
Electronic Health Record Opportunities
What information about pressure injury risk factors … logical place in the record to collect, organize, and assess information about patient pressure injury risk … plan/documentation
Staff Education: RN, CEO, CNO, PCT
2-hour didactic competency training:
Braden risk
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talkingquality.ahrq.gov/patient-safety/settings/ambulatory/index.html
July 01, 2022 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … 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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talkingquality.ahrq.gov/talkingquality/measures/understand/patient-comments.html
February 01, 2016 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … J Risk Uncertain 1997;14(3):235–57. [4] Schwartz LM, Woloshin S, Black WC, Welch HG. … What does it mean to understand a risk? Evaluating risk comprehension. … Risk as feelings. Psychol Bull 2001 Mar;127(2):267-86. [7] Redelmeier DA, Rozin P, Kahneman D.
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talkingquality.ahrq.gov/nhguide/toolkits.html
September 01, 2017 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … Residents and their family members may not know how antibiotics should be used or understand the risks … them understand what the nursing home is doing to make sure antibiotics are used properly, what the risks
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talkingquality.ahrq.gov/hai/cusp/videos/index.html
September 01, 2019 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … 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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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/safemedication.pptx
May 01, 2017 - Admin.
3
High-Alert Medications1
High-alert medications are “drugs that bear a heightened risk of … These medications require special safeguards to reduce the risk of errors, such as the following:
Improving … Ensures a shared mental model of plan of care and perceived risks—
between shifts
between units
between … Admin.
15
Key Safety Elements: Patient and Family Engagement
Discuss risks and benefits of oxytocin … Admin.
26
Key Safety Elements: Patient and Family Engagement
Discuss risks and benefits of intrapartum
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talkingquality.ahrq.gov/evidencenow/heart-health/smoking/pcor.html
August 01, 2018 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … Resource description: This EvidenceNOW fact sheet provides an overview of PCOR findings about the risks
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talkingquality.ahrq.gov/news/newsletters/e-newsletter/876.html
August 01, 2023 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … monitoring, also based on the systematic review, found postpartum home monitoring significantly reduced the risk … Implementation of suicide risk estimation analytics to support mental health care for quality improvement … Factors associated with lung cancer risk factor documentation. … Adapting an electronic STI risk assessment program for use in pediatric primary care.
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talkingquality.ahrq.gov/research/findings/final-reports/index.html?page=2
September 01, 2018 - Planning
(7)
Nursing Homes
(7)
Patient Safety Measure Development and Implementation
(7)
Risk … Patient Safety Tools Publication Date: April 2016
Developing and Disseminating a Patient Safety Risk … Grant Number: R13 HS 021824 Topic(s): Detection/Triggers, Healthcare Facility Design, Risk Assessment … Development of a Community-Wide Real-Time Health Information Exchange–Based Hospital Readmission Risk … Grant Number: R21 HS 022578 Topic(s): Patient Safety Tools, Risk Assessment Publication Date: September
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talkingquality.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
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talkingquality.ahrq.gov/patient-safety/resources/learning-lab/ehrll-long-desc.html
April 01, 2022 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … 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