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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/vtguide/umich-slides.ppt
May 20, 2012 - Presentation
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VTE Prevention:
An Institution-wide Initiative
University of Michigan
Caprini VTE risk … *
Key Strategies
Scope: ALL adult inpatients
Standardized VTE Protocol – Caprini model
Mandatory risk … of EVERY VTE event that occurs in the health system for preventability
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Closing the Gap…
VTE Risk … VTE risk factor reorganization based on Clinical Advisory Group feedback (by risk factor category rather … facilitate discussions
Point total calculated for user, prophylaxis recommendation based on risk
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www.ahrq.gov/hai/tools/cauti-hospitals/toolkit-impl.html
October 01, 2020 - Poster on Urinary Catheter Risks and Indications ( PDF , 570 KB) (Appendix E of Toolkit for Reducing … Tract Infections in Hospital Units: Implementation Guide)
Educate and motivate staff regarding the risks … in Hospital Units: Implementation Guide)
Educate staff in removal of indwelling urinary catheters, risks … Risks of overuse of urine culturing are also covered in this tool. … Archived Webinars
Building a Team and Process to Reduce CAUTI Risk (April 8, 2014)
Accessible
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects.pptx
December 01, 2017 - How will you reduce the risk of it happening again?
How will you know the risk is reduced? … How will you reduce the risk of the defect happening again?
How will you know the risk is reduced? … Do staff believe risks were reduced? … This is an iterative process.
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How Will You Know Risks Were Reduced? … Show your staff that you’ve reduced the risks for patient harm.
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www.ahrq.gov/research/findings/final-reports/ssi/ssiexh2.html
April 01, 2018 - Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection
Exhibit … Designing and Testing Methods to Stratify Risk of Surgical Site Infections
Chapter 4. … Initial Risk Factors
Appendix J. Additional Risk Factors
Appendix K. … Final Risk Factors
Appendix L. … Surgeons' Acceptance of Surgical Site Infection Risk Adjustment Models
Appendix T.
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www.ahrq.gov/research/findings/final-reports/ssi/ssiapf.html
April 01, 2018 - Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection
Appendix … Designing and Testing Methods to Stratify Risk of Surgical Site Infections
Chapter 4. … Initial Risk Factors
Appendix J. Additional Risk Factors
Appendix K. … Final Risk Factors
Appendix L. … Surgeons' Acceptance of Surgical Site Infection Risk Adjustment Models
Appendix T.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/spectorhudak.ppt
December 01, 2013 - Residents' changing risk profiles not readily available
Daily documentation is fragmented across … MDS is focused on chronic care not acute changes that increase risk if not managed
Most staff not using … identification from literature
Clinical expert panel review of tools and risk criteria
Front line … rules & impact to work flow
Clinical Decision Support Intervention
Identify risk criteria … at risk (clinical assessments, MDS assessment, orders)
Design simple weekly reports for front line
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/care/resources/ontime/pruprev/spectorhudaktxt.html
December 01, 2017 - Challenges for managing clinical risk:
Residents' changing risk profiles not readily available. … Clinical expert panel review of tools and risk criteria. … Pilot test with actual data risk rules & impact to work flow. … Create resident risk profile reports, profile changes in risk:
Incorporate multiple information sources … Incorporate risk reports with ongoing processes & structures.
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www.ahrq.gov/research/publications/pubcomguide/pcguide1.html
March 01, 2025 - activities including: research projects (surveys, interviews, questionnaires, epidemiology studies, health risk … Report results in comparative terms to describe the magnitude of effect (units, relative risks, absolute … For example, if the risk of cancer in men is 3/1,000 and the risk in women is 6/1,000, then the relative … risk for women is 2 (twice the risk in men).
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www.ahrq.gov/hai/cauti-tools/guides/implguide-pt3.html
October 01, 2015 - Poster on Urinary Catheter Risks and Indications
Appendix F. … the urinary catheter, and consider providing them with educational materials on the risks of CAUTI. … Explain to the patient the increased risks associated with use of a urinary catheter and the resulting … Poster on Urinary Catheter Risks and Indications
Educate and motivate staff around the risks, indications … Risks of overuse of urine culturing are also covered in this tool.
Appendix M.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/impmenu.html
December 01, 2017 - huddle
Weekly risk huddle of Nursing and Rehab
Weekly wound review meetings …
Weekly risk meeting
On-Time Pressure Ulcers at Risk for Delayed Healing … for delayed healing
Skin rounds
Weekly nutrition risk huddle
… Weekly risk huddle for Nursing and Rehab
Weekly wound review meetings
… Weekly wound rounds
Weekly risk meetings
On-Time Weekly Wound Rounds Report
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-slides.pptx
June 01, 2021 - What could you do to reduce the risk?
How do you know that risk was reduced? … Negative contributing
factors are those that
harmed or increased risk
of harm
Positive contributing … factors limited the impact
of harm
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Changing the System
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What Could You Do To Reduce the Risk … modifications New device usability testing before purchasing
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Changing the System
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How Do You Know the Risk … Do staff believe risks were reduced?
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/chipra_1415-p009-1-ef.pdf
March 01, 2015 - Measures: Availability of Outpatient Maternal
Fetal Medicine and Specialty Care for Women
With High-Risk … Data Source(s)
Availability of Outpatient Maternal Fetal Medicine and Specialty Care for Women High-Risk … Pregnancies (HROB V)
The number of eligible
high-risk pregnant women
who have the specified
number … Overall number of eligible
qualifying high-risk
pregnancies using the
indicated look back period. … Availability of Multidisciplinary Outpatient Care for Women with High-Risk Pregnancies (HROB VI)
The
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/edenvironmentalscan/edenvironmentalscan.pdf
December 01, 2014 - What are the risk factors for patients at high risk for discharge failure?
2. … contribution of each risk. … asthma found that those with private
insurance were more likely to respond to telephone followup (relative … was a risk factor for 28-day ED revisit (OR 2.43).20 Dyspnea as a
symptom was a risk factor for 72- … If it is an article about risk factors, answer the
risk factor questions.
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www.ahrq.gov/research/findings/final-reports/ssi/ssiexh8-10.html
April 01, 2018 - Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection
Exhibits … Designing and Testing Methods to Stratify Risk of Surgical Site Infections
Chapter 4. … Initial Risk Factors
Appendix J. Additional Risk Factors
Appendix K. … Final Risk Factors
Appendix L. … Surgeons' Acceptance of Surgical Site Infection Risk Adjustment Models
Appendix T.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/timeline.html
December 01, 2014 - The facilitator reviews ways risk information is transmitted to clinical staff and ways care plans are … populated on the report to ensure that data on the report agree with staff knowledge of residents’ health/risks … The first report, Intervention History for Nutrition Risk Reports: High Risk and Medium Risk , focuses … on intervention history of residents with nutrition risks. … Intervention History for Nutrition Risk. Reports: High Risk and Medium Risk.
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7c.html
October 01, 2014 - Does the risk assessment tool include a Braden Scale or modified Braden Scale score? … Was the patient identified on admission as being at risk for pressure ulcer development? … Provider orders special diet within 24 hours of risk identification
g. … Provider orders special diet within 24 hours of risk identification
h. … how to evaluate the performance of standardized risk assessment.
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www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7c.html
October 01, 2014 - Does the risk assessment tool include a Braden Scale or modified Braden Scale score? … Was the patient identified on admission as being at risk for pressure ulcer development? … Provider orders special diet within 24 hours of risk identification
g. … Provider orders special diet within 24 hours of risk identification
h. … how to evaluate the performance of standardized risk assessment.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/head-bed-elevation-litreview.docx
January 01, 2017 - guidelines, and newer publications in the field accept HOB elevation as an effective, low-cost, and low-risk … Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: A … PRO: Clinical review – This article summarized the epidemiology, pathophysiology, and specifically risk … After evaluation of potential benefits and risks, the authors recommended considering several specific … Three studies that evaluated comparative risks associated with semirecumbent positioning were reviewed
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/overviewhandouts4.html
December 01, 2017 - worksheet that identifies details about current processes at the facility to identify residents at risk … Facilitator reviews ways risk information is transmitted to clinical staff, and ways care plans are updated … populated on the report to ensure that data on the report agree with staff knowledge of residents' health/risks … The first report, Intervention History for Nutrition Risk Reports: High Risk and Medium Risk, focuses … on intervention history of residents with nutrition risks.
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www.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T2-Talking_with_Residents_Family_Members_Final.docx
October 01, 2016 - dialogue between nurses or prescribing clinicians and residents’ family members about antibiotics and the risks … points are designed to: (1) educate residents’ family members about antibiotics and the associated risks … However, watchful waiting is a good way to make sure that your family member avoids the risks of antibiotics … What are the risks—or harms—of antibiotics? … What is our nursing home doing to decrease the chance of these risks?