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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module2/mod02-business-case-worksheet.pdf
April 01, 2016 - Adapt the business case to the audience being addressed, whether it is the CEO, risk manager, or frontline … – Alignment of the plan to the organization’s
strategic and risk/quality/patient safety goals. … Implementation Risk
■ Assessment of the Implementation Risk should
address … risks associated with allocating resources
(human and other) to implement, spread, or
sustain the … )
■ Include potential risks to the organization if the
practices and principles are not fully integrated
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www.ahrq.gov/sites/default/files/2024-04/eskandari-raval-report.pdf
January 01, 2024 - undergoing colectomy,
reducing incidence of surgical site infections and identifying patients at risk … Caprini taught the audience his VTE
Risk Assessment Model, the Caprini scale. … Risks and benefits of different
chemical prophylaxis were also discussed. … Oncologic patients have an increased risk of VTE. … Bentrem encouraged high-risk
medical oncology patients to receive chemical prophylaxis as well.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxoverview-ig.pdf
June 02, 2025 - In other words,
if we knew who was at high risk or had a recent change in
risk, would we do things … Some identify a profile of risk
factors; others focus on a particular risk factor. … MATERIALS:
Falls High-Risk Report
Quarterly Summary of Falls Risk Factors (by Unit or Facility … Show recent changes in risks.
Profile risks for each resident in the report. … The Self-Assessment Worksheet is designed to help nursing home
staff review how they:
Screen for risks
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-guide.pdf
June 02, 2025 - feasibility and
usefulness and content is based on review of the published
literature concerning the risks … Some identify a profile of risk factors; others focus on a
particular risk factor. … causes of
risk changes. … Show recent changes in risks.
Profile risks for each resident in the report. … The Self-Assessment worksheet is designed to help nursing home
staff review how they:
Screen for risks
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/slides.html
December 01, 2014 - May focus on a particular risk factor. … Identify residents with recent changes in risks.
Profile risks for each resident in report. … 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 changes to care plans. … How the nursing home identifies risk factors for adverse events and communicates changes in risk to clinical
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www.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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www.ahrq.gov/sites/default/files/wysiwyg/sdm/share-approach/share-facilitator-guide.pdf
October 01, 2024 - > Which of these potential risks worries you the most? … > I discussed the risks and benefits of each option with my patient. … With a blood thinner, his risk would go down to 1.1% per year. … Use absolute instead of relative risk
> Terrible: “There is a 300% increased risk of stroke without … Keep denominators the same
Use absolute instead of relative risk
Frame both positively and negatively
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module2/module2-obtaining-organizational-buy-in-support.pptx
August 14, 2015 - 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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www.ahrq.gov/sites/default/files/2024-02/yazdany-report.pdf
January 01, 2024 - Results: The project generated new epidemiological evidence of patient safety risks and
adverse events … We also
sought to use epidemiological data to develop and implement “eMeasures” to monitor these
risks … risks. … the increased number of medications available and fractured care across multiple providers,
safety risks … At least 25% of
patients with the highest-risk conditions (e.g.,
vasculitis) or highest-risk immunosuppressants
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www.ahrq.gov/research/findings/final-reports/stpra/stpraapa3.html
April 01, 2018 - Results
The odds ratios for SSI in each NNIS System risk index category (compared with the risk in … Risk factors related to operating rooms include patient-associated risks, the operating room environment … The CD4+ lymphocyte count is clinically relevant for stratifying the risks in HIV-infected patients. … Risk Infection Factors in the Total Hip Replacement - Arjona et al. … Spinal fusion without instrumentation has a 1-5% risk of infection.
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www.ahrq.gov/sites/default/files/2025-02/jones-selna-report.pdf
January 01, 2025 - The purpose of this project was to use
Failure Mode Effects Analysis (FMEA) to identify modifiable risks … technique to identify risks associated with inpatient-to-ambulatory transitions; the
FMEA, in turn, … analysis techniques as a means to identifying and reducing risks. … Though this is a
sensible approach to understanding how risks emerge, there are fundamental challenges … analysis
may convey an impression that risks are well understood when, in fact, meaningful sources
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-facguide.docx
January 01, 2017 - It reduces risks for future patients by improving work processes and increasing compliance. … Slide 27
How Will You Know Risks Were Reduced?
ASK:
How will you know the risks were reduced? … Slide 29
How Will You Know Risks Were Reduced? … ASK:
Are there other ways to assess whether risks were actually reduced? … With supporting data, show your staff the reduced risks for patient harm.
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www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guide3.html
February 01, 2016 - Choose the Model To Assess VTE and Bleeding Risk
Chapter 5. … for VTE or without multiple VTE risk factors. … the highest of all risks for VTE. … In view of underlying high risk, even patients who have an active malignancy without additional risk … patients, or with LMWH for higher risk patients.
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www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide3.html
February 01, 2016 - Choose the Model To Assess VTE and Bleeding Risk
Chapter 5. … for VTE or without multiple VTE risk factors. … the highest of all risks for VTE. … In view of underlying high risk, even patients who have an active malignancy without additional risk … patients, or with LMWH for higher risk patients.
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www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dxsafety-brief-ai-wave.pdf
June 01, 2025 - Similarly, many widely used clinical risk calculators, such as the CHA₂DS₂-VASc score for stroke
risk … delivery, it also
introduces new risks that must be carefully understood and addressed. … To maximize
the benefits of AI while minimizing harm, it is critical to examine the underlying risks … In healthcare, hallucinations pose an even greater risk. … Given the risks of bias, hallucinations, and lack of
transparency described above, this shift places
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/133-clabsi-prevention-central-line-insertion.docx
October 01, 2024 - Each location has its own risks and should be considered on a case-by-case basis.
· Subclavian vein: … catheter-related thrombosis.
· Femoral vein: Should be avoided if possible, due to significant increase in risk … of infection.7
· Risks include: infection due to proximity of the groin, catheter-related thrombosis … Risk of infection due to central venous catheters: effect of site of placement and catheter type. … The risk of bloodstream infection associated with peripherally inserted central catheters compared with
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/003-ss-antimicrobial-prophylaxis-part-2-fg.docx
April 01, 2025 - There are several risks associated with prolonged prophylaxis. … , and increased risk of acute kidney injury. … Slide 18
Benefits and Risks of IV Vancomycin
SAY:
There are benefits to including IV vancomycin as … Therefore, again, the benefits must be weighed against the risks. … Slide 39
Case Study: How To Know Risk Is Reduced?
SAY:
How do you know that risk is reduced?
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/factraining.html
September 01, 2017 - Risk. … Content is based on review of the published literature on the risks and treatments associated with the … Transfer Risk Reports (high- and medium-risk residents) provide a weekly snapshot of residents at risk … Show recent changes in risks.
Profile risks for each resident in the report. … The Self-Assessment worksheet is designed to help nursing home staff review how they:
Screen for risks
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/001-ss-antimicrobial-prophylaxis-1-fg.docx
April 01, 2025 - strategies to reduce SSI risk. … prophylaxis agents effective against MRSA and how to appropriately use them, while balancing benefits and risks … benefit of including vancomycin as part of antimicrobial prophylaxis should be weighed against the risks … In light of this, and balancing the risks and benefits of using vancomycin, who should receive vancomycin … are four phases in which interventions related to antimicrobial prophylaxis take place to reduce the risks
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/124-cusp-science-safety-fg.docx
April 01, 2025 - Slide 1
Educational Objectives
SAY:
This presentation will describe the patient safety risks that … Slide 3
Risks of Healthcare-Associated Infections
SAY:
The risk of healthcare-associated infections … The risk is even higher for patients in intensive care units, where 30 percent develop an HAI. … This reduces the risk that future patients will be harmed by the same type of error. … He assessed the patient for her venous thromboembolism (VTE) risk and followed the VTE risk protocol,