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  1. 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
  2. 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.
  3. 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
  4. 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
  5. 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
  6. 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
  7. 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
  8. 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.
  9. 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 risksrisks. … 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
  10. 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.
  11. 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
  12. 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.
  13. 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.
  14. 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.
  15. 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
  16. 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
  17. 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?
  18. 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
  19. 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
  20. 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,

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