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www.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-fac-guide.html
February 01, 2017 - Slide 28: How Will You Know Risks Were Reduced? … Ask:
How will you know the risks were reduced? … Slide 30: 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/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmodap3b.html
October 01, 2014 - Risk assessments of residents for falls include all of the following except:
Strength. … The team has to watch out for any environmental risks.
Everything has to be documented. … An individual's condition and treatment can directly impact his/her fall risk. … The team has to watch out for any environmental risks.
Everything has to be documented. … An individual's condition and treatment can directly impact his/her fall risk.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b1_combo_applyingqis.pdf
March 01, 2016 - Hospital A has a risk-
adjusted rate of 0.025 = (0.02/0.04) * 0.05) and Hospital B has a risk adjusted … defined above,
ˆˆk k kj je Xβ= the predicted probability of QI k
occurring on discharge j given the risks … )
present in discharge j where ˆ kβ is a vector of
parameter estimates from a regression of the risks … of the risk-adjusted rate over time. … Also used instead of the risk-
adjusted rate for comparing with
others if the risk-adjusted rate is
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/b1_pdi_applyingpdis.pdf
March 01, 2016 - Hospital A has a risk-
adjusted rate of 0.025 = (0.02/0.04) * 0.05) and Hospital B has a risk adjusted … defined above,
ˆˆk k kj je Xβ= the predicted probability of QI k
occurring on discharge j given the risks … )
present in discharge j where ˆ kβ is a vector of
parameter estimates from a regression of the risks … of the risk-adjusted rate over time. … Also used instead of the risk-
adjusted rate for comparing with
others if the risk-adjusted rate is
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/170-cusp-science-safety-notes.docx
October 01, 2024 - Slide 3
Risks of Healthcare-Associated Infections (HAI)
SAY:
The risk of healthcare-associated infections … The risk is even higher for patients in intensive care units (ICU), where 30 percent develop an HAI. … This reduces the risk that future patients will be harmed by the same type of error. … Given her trauma, he was concerned about Susan’s bleeding risks. … The hospital didn’t have a standardized protocol for VTE risk assessment.
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/16801-Sangasubana-draft-1.pdf
February 28, 2010 - ), we chose the following four independent variables to manipulate
risks associated with the information … Product-Category Risk (PCR): This variable was manipulated by varying the level of risk
perceived by … ) vs. dry skin (low risk).
4. … “Perceived likelihood of risks in self-medication practices.” … “A model of perceived risk and intended risk-handling activity.”
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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/teamstepps/diagnosis-improvement/dxsafety-infographic.pdf
February 01, 2022 - Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report. … harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures. … KC/PDFs/Insight_Comm_2012.pdf
https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures … https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures
-
www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dxsafety-infographic.pdf
February 01, 2022 - Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report. … harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures. … KC/PDFs/Insight_Comm_2012.pdf
https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures … https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module3/module3_slides_best-practices.pptx
June 16, 2017 - Fall Risk Assessment
‹#›
Step 1: Fall Risk Screening/Assessment
Use a reliable, prospectively … Other risks
IV pole
Orthostatic hypotension
Oxygen tubing
Clutter in the patient’s room
Vision problems … 25-45: Moderate risk
>45: High risk ______
* Weak gait: Short steps (may shuffle), stooped but able … 25-45: Moderate risk
>45: High risk 50
‹#›
Assessment of Risk Factors in Your Hospital
The questions … Identify key elements of a fall risk factor assessment.
Choose a tool for assessing risk factors.
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www.ahrq.gov/hai/cusp/modules/apply/alt-text.html
March 01, 2013 - increases risk where risk is not recognized, or is mistakenly believed to be justified
Reckless … At-risk behavior is a choice made while believing that the risk is insignificant or justified. … Coaching is the best response to at-risk behavior. … Reckless behavior is the conscious disregard of substantial and unjustifiable risk. … communication strategies from CUSP and TeamSTEPPS®
The communication that takes place between two people risks
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www.ahrq.gov/research/findings/final-reports/stpra/stpraapc.html
April 01, 2018 - Risk-Informed Interventions
Chapter 4. Conclusions and Next Steps
Appendix A. … If and when is the patient or family instructed of potential risks for surgical site infection? … patient populations
At-risk procedures, such as those requiring invasive devices
Causes, risks, … What the potential infection risks with this process? … What steps does the surgical team take to reduce the risk?
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www.ahrq.gov/research/findings/studies/index.html?page=401
January 01, 2024 - Keywords: Mortality, Behavioral Health, Patient-Centered Outcomes Research, Risk
Krouse RS , … Adverse Drug Events (ADE), Dementia, Elderly, Nursing Homes, Medication
Du XL , Zhang Y Risks … Risks of venous thromboembolism, stroke, heart disease, and myelodysplastic syndrome associated with … bleeding in AF patients when compared with HAS-BLED and ATRIA risk scores. … The ORBIT bleeding score: a simple bedside score to assess bleeding risk in atrial fibrillation.
-
www.ahrq.gov/hai/tools/mvp/modules/technical/ltvv-lit-review.html
January 01, 2017 - patients, or for high-risk surgery. … Thus, the risks and benefits of lung-protective ventilation need to be balanced in each individual patient … lung-protective ventilation, as compared with 55 of 200 (27.5%) assigned to nonprotective ventilation (relative … intubation for acute respiratory failure, as compared with 34 (17.0%) assigned to nonprotective ventilation (relative … Therefore, the risks and benefits should be balanced for each patient.
Kilickaya O, Gajic O.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/ltvv-litreview.docx
January 01, 2017 - patients, or for high-risk surgery. … Thus, the risks and benefits of lung-protective ventilation need to be balanced in each individual patient … lung-protective ventilation, as compared with 55 of 200 (27.5%) assigned to nonprotective ventilation (relative … intubation for acute respiratory failure, as compared with 34 (17.0%) assigned to nonprotective ventilation (relative … Therefore, the risks and benefits should be balanced for each patient.
23. Kilickaya O, Gajic O.
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www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-slides.html
December 01, 2017 - How will you reduce the risk of it happening again?
How will you know the risk is reduced? … Slide 13: How Will You Reduce Risk of Recurrence? … Slide 16: How Will You Reduce Risk of Recurrence? … Slide 19: How Will You Know Risks Were Reduced? … Post the stories of reduced risks (with data!).
Share with others.
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www.ahrq.gov/sites/default/files/2024-07/domino-report.pdf
January 01, 2024 - Quality (AHRQ R21 HS19532).
1
ABSTRACT
Purpose: Physician-patient miscommunication with inadequate risk … Risk management resources were compared by estimated time and costs for processing patient
complaint … Informed
consent accounted for 41% of total risk management files. … the lists of risks to combine minor risks lacking numerical estimates of probability. … of total
risk management files) and 47 medical errors (24% of total risk management files).
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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/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
-
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