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talkingquality.ahrq.gov/cpi/about/impact/index.html
April 01, 2017 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … Hospital-acquired conditions have relatively high mortality risk and include central line-associated … Preventing central line-associated blood stream infections, the top-ranked mortality risk among all hospital-acquired
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/ced-appendix3-data-abstraction.xlsx
June 24, 2022 - ’s local data warehouse and research portfolio, which may include legal counsel to manage liability risk … NAM2019 What special vulnerabilities or risks are anticipated in the study population? … NAM2019 The risk/benefit ratio of trial participation? … Generally, an intervention is not reasonable and necessary if its risks outweigh its benefits. … Generally, an intervention is not reasonable and necessary if its risks outweigh its benefits.
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-patient-safety-culture-brief.pdf
September 01, 2016 - Patient Safety; Hospital Risk:
Perspectives of Hospital C-Suite and Risk Managers. … closer look at associations between
hospital leadership walkrounds and patient safety climate and
risk
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talkingquality.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/safe-electronic-fac-guide.html
July 01, 2023 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … of transition communication techniques to ensure a shared mental model of plan of care and perceived risks … The process could include a discussion of risks and benefits of using continuous EFM versus intermittent
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
May 20, 2016 - Quality Forum states: “Healthcare organizations must systematically identify
and mitigate patient safety risks … 11 Abdominal Aortic Aneurysm (AAA) Repair Mortality Rate
• Using an individualized assessment of risk … factors for each specific patient allows
categorization of operative mortality risk into low (l%-3%
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4_combo_bestpracticescover.pdf
June 05, 2016 - Rate―Injury to Neonate: The existing literature on birth trauma
and injury to the neonate suggests multiple risk … Given this heterogeneity, creating one best practices form to address
the various risk factors would
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/shareddecisionmaking/tools/tool-4/share-tool4.pdf
April 01, 2014 - Fill out complex forms
› Find providers and services
› Share their health history
› Understand risk … chronic illness
› Skip needed tests
› Underuse preventive health care
Some groups are at higher risk
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talkingquality.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/urine-culturing/antibiotic-stewardship/part-2-slides.html
February 01, 2019 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … Antibiotics can cause harm to residents
High risk of side effects and adverse events. … Major risk factor for Clostridium difficile infection.
Driver of antibiotic resistance.
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/clabsitools/clabsitoolsap5.doc
December 11, 2012 - , eye protection
· Assistant: Cap, mask, isolation gown and gloves, eye protection (if at risk
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_lowvision.pdf
May 01, 2017 - QI and patient safety during a time when
they experienced an increase in patient load and higher
risk … for more high-risk patients than ever before, so it is even
more crucial that we do things right…it’ … It is a safe way to deal with high-risk situations. … This variation created a risk
of both time lags in patient care and miscommunication
among the care … However, as one project leader soon recognized, “If
we’re going to do a [hemorrhage] risk assessment
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_fullcolor.pdf
May 01, 2017 - QI and patient safety during a time when
they experienced an increase in patient load and higher
risk … for more high-risk patients than ever before, so it is even
more crucial that we do things right…it’ … It is a safe way to deal with high-risk situations. … This variation created a risk
of both time lags in patient care and miscommunication
among the care … However, as one project leader soon recognized, “If
we’re going to do a [hemorrhage] risk assessment
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/lab-testiing/lab-testing-toolkit.pdf
December 01, 2017 - Assessing Risk in Testing
We know that:
• The risk of an event is related to its frequency and the … • Balancing these two aspects of risk can be challenging. … • It is important to stay focused on office systems in managing risk. … Results
• The highest scores for “office total” show areas where staff have identified the
greatest risks … do not eliminate all errors.
• A failure to monitor automated processes may introduce patient safety risks
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talkingquality.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module3/mod3-facguide.html
March 01, 2017 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … To achieve optimal outcomes, organizations must design systems that minimize risks. … It's important to reinforce behaviors that reduce risk and deter behaviors that increase risk. … All humans make mistakes, and it is important to differentiate between human error and at-risk behavior
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/rapid-response/rapidresponse_facguide.pdf
May 01, 2017 - maternity patient who has deteriorated
physiologically; and
• be able to intervene to minimize risk … Form
• Root Cause Analysis
• Eindhoven Model
• Failure Mode and Effects Analysis
• Probabilistic Risk … transition communication
techniques to ensure a shared mental
model of plan of care and perceived risks
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/ahrq-network-factsheet.pdf
February 01, 2022 - especially vulnerable, and their reliance
on nursing home staff put these essential workers at high risk
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/labordel.pdf
March 18, 2014 - communication techniques taught in this module could have avoided placing this
patient at unnecessary risk … s unfolding event, no one assumes leadership for the case and the patient is
placed at unnecessary risk … At exactly that moment, the Triage nurse receives a call that a high-
risk patient in acute distress … This high-risk
patient ties up three nurses, two residents, and a covering attending obstetrician for … Instructor Comments
In this situation, the RN team leader becomes aware of a potential risk for the
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/webinars/webinar6_falls_sustainingpractices.pdf
January 01, 2013 - specific
interventions
for fallers
Examples of Process Measures
Percentage of—
• Patients at risk … – For instance, reward unit staff the first time they
complete a fall risk assessment form correctly
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/ced-appendix2-comments.xlsx
October 12, 2022 - systematic approach to generating RWE that would allow for a quicker confirmation of the benefits and risks … Benefits and risks across diverse clinical populations in diverse clinical settings, without imposing … systematic approach to generating RWE that would allow for a quicker confirmation of the benefits and risks … Benefits and risks across diverse clinical populations in diverse clinical settings, without imposing
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring_facguide.docx
May 01, 2017 - of transition communication techniques to ensure a shared mental model of plan of care and perceived risks … The process could include a discussion of risks and benefits of using continuous EFM versus intermittent
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/research-centers/bundlingcps.pdf
March 01, 2014 - Reduction of 30-day postdischarge hospital readmission or emergency department (ED)
visit rates in high-risk … although some positive effect of
bundling was observed for sub-
groups
Galvan, 2006
Single-session risk … clinical preventive services, such as inadequate provider
time to discuss the bundles with a patient, risk