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www.cahps.ahrq.gov/health-literacy/professional-training/shared-decision/workshop/mod2-slides.html
September 01, 2020 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … Know the benefits and risks of each option
Understand how they relate to your patient's situation and … Compare treatment options—risks and benefits.
Questions to ask provider. … Help clarify patients' preferences for risks and benefits of options. … Improves accurate risk perceptions of possible benefits and harms among patients.
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www.cahps.ahrq.gov/research/findings/studies/index.html?page=1
January 01, 2024 - Among Hispanic participants, incarceration was associated with hyperglycemia (Adjusted Risk Ratio (ARR … ): 2.1), but not with hypertension risk. … Associations between incarceration history and risk of hypertension and hyperglycemia: consideration … Automating risk stratification for geriatric syndromes in the emergency department. … The study found that treatment by the highest-rated agencies available decreased risks of hospitalization
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www.cahps.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-slides.html
July 01, 2023 - Root Cause Analysis
Learn From Defects Form
Failure Mode and Effects Analysis
Probabilistic Risk … Worksheet
Discovery Form
Root Cause Analysis
Failure Mode and Effects Analysis
Probabilistic Risk … Discuss the three greatest risks.
Rank these factors. … Question 3: What will you do to reduce the risk of reoccurrence? … Sensemaking of patient safety risks and hazards. Hlth Svcs Res 2006;41(Aug 4 Pt 2.):1555-75.
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/overview/background/measures-PHP-38.pdf
December 17, 2010 - Measure Name: Cesarean Rate for Low-risk First Birth Women
C. Measure Definition
a. … infants delivered via elective cesarean delivery had significantly higher rates of mortality
(adjusted risk … ratio [aRR]: 2.1), risk of special care admission (aRR: 1.4), and respiratory morbidity (aRR: 1.8)). … C-section 17.8%
No data by race/ethnicity or other, and this rate is not limited to low-risk
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www.cahps.ahrq.gov/health-literacy/professional-training/lepguide/about.html
September 01, 2020 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … the issue of patient safety for LEP and culturally diverse patients, including common causes and high-risk … impact of an increasingly diverse nation on health care delivery, quality and cost drivers, and role of risk … recommendations that aim to both improve detection of medical errors across diverse populations and prevent high-risk … At minimum, hospitals should focus on addressing the root causes that lead to high-risk scenarios for
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www.cahps.ahrq.gov/funding/grantee-profiles/grtprofile-dykes.html
September 01, 2022 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … To use it, clinicians determine a hospital patient’s risk of falling and develop a tailored falls prevention … Then hospital staff talk to patients as part of routine care at the bedside about their risk for falling … the most feasible falls prevention strategies for a community-based patient using three individual risk … factors: mobility limitations; medications that can increase the risk of falling; and osteoporosis.
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www.cahps.ahrq.gov/news/blog/ahrqviews/delivery-primary-care.html
November 01, 2022 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … improved the delivery of heart healthcare in four important areas:
Counseling on aspirin use among high-risk … support provided to mostly small, rural practices in North Carolina reduced 10-year cardiovascular risk … for patients at high risk of a stroke or heart attack by using a risk-stratified, population management
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/module5_pressureinjury-msmt_slides.pptx
July 02, 2008 - At least one or two care processes, such as skin assessment and pressure injury risk assessment. … Ensure the known risk factors for pressure injuries are assessed. … Tool 5D
39
Assessment of Care Planning
All the risk factors identified in the pressure injury risk … Tailor your approach to each patient, based on the patient’s risk factors. … Pressure injury risk factor assessment is performed accurately within 24 hours of admission.
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www.cahps.ahrq.gov/health-literacy/professional-training/lepguide/chapter3.html
September 01, 2020 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … nurses, technicians, front desk staff, and interpreters) will be able to:
Understand patient safety risks … team member can use to stop the action at any time when there is any concern for miscommunication or risk … The module provides facts and statistics regarding the increased patient safety risk to LEP patients … Hospitals will highlight risks specific to their LEP population and work with unit staff to refine and
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-208-section6b.pdf
May 17, 2019 - Tables 8a-e: Risk … Risk Estimate Adjusted Model- 7 Day
Estimat
e Std Dev P-Value
Estimat
e LCL
Estimat
e UCL OR … Risk Estimate Adjusted Model- 14 Day
Estimat
e Std Dev P-Value
Estimat
e LCL
Estimat
e UCL OR … Risk Estimate Adjusted Model- 30 Day
Estimat
e Std Dev P-Value
Estimat
e LCL
Estimat
e UCL OR … Risk Estimate Adjusted Model- 365 Day
Estimat
e Std Dev P-Value
Estimat
e LCL
Estimat
e UCL
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/candor-acknowledgments.pdf
September 14, 2017 - Boothman, J.D., Executive Director, Clinical Safety and Chief Risk Officer,
University of Michigan Health … ARM, formerly with the University of Illinois-Chicago and
now Director, Office of Patient Safety and Risk … Scott, Ph.D., R.N., Manager of Patient Safety and Risk Management, University of
Missouri
- Kelly … Driver, J.D., M.B.A., CEO of The Risk Authority Stanford and Chief Risk Officer of
Stanford Health … Hickson, M.D., Senior Vice President for Quality, Safety and Risk Prevention,
Assistant Vice Chancellor
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www.cahps.ahrq.gov/patient-safety/settings/index.html
July 01, 2023 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … Setting
AHRQ has developed a wealth of materials focused on a wide range of patient safety risks
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www.cahps.ahrq.gov/evidencenow/projects/heart-health/about/cooperatives/nyc.html
March 01, 2021 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … need to help their patients adopt the ABCS of cardiovascular disease prevention: A spirin in high-risk … Heart disease is the primary cause of death in the city, and prevalence of cardiovascular disease (CVD) risk … support ABCS-driven care
Three expert webinars on topics related to evidence-based management of CVD risk … care practices [AcademyHealth, 2017]
Using Practice Facilitation in primary care settings to reduce risk
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www.cahps.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module1/mod1-slides.html
March 01, 2017 - Slide 18: Understanding Risk and Human Behavior 1
Human Error:
Inadvertently completing the wrong … At-Risk Behavior:
Choosing to behave in a way that increases risk where risk is not recognized, or … Reckless Behavior:
Choosing to consciously disregard a substantial and unjustifiable risk.
1. … Slide 19: Managing Error and Risk 1
Human Error
At-Risk Behavior
Reckless Behavior … believed insignificant or justified
Manage through:
Removal of incentives for at-risk behaviors
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www.cahps.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apd.html
August 01, 2022 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … CULTURE
Have leaders established methods to identify risks and provide employees opportunities to … FUTURE RISKS
Are there other areas in the organization where this could happen?
… FUTURE RISKS
Are there opportunities to improve trainings, competencies and orientation sessions
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module5/module5_tools.docx
August 03, 2017 - Medication affecting risk of falls
Sedative and psychotropic medication, or medication with drowsiness … ”*:
Number of higher risk patients:
8
Chart: full medication review requested? … For any of the 20 patients who are “higher risk”*:
Number of higher risk patients:
Chart: full medication … * In some wards all patients are counted as high risk, for other wards only some. … Completion Date for Plan
Fall risk factor assessment is performed within 24 hours of admission
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0129table9.pdf
January 01, 2008 - Table 9 – Analysis of Disparities in Readmission Risk Based on Race/Ethnicity
2005-2009 AHRQ Revisit … [1.20 – 1.29]
Other 1.03 [0.98 – 1.07]
Table 10 – Analysis of Disparities in Readmission Risk … 1.26]
Native American 1.09 [0.99 - 1.20]
Table 11 – Analysis of Disparities in Readmission Risk
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/module5_pu_measurement.docx
January 01, 2016 - Performance of care planning that addresses each risk factor identified during risk factor assessment … Slide 38
SAY: Risk assessment is the cornerstone of prevention. … Calculate the percentage of patients who have a completed risk score. … Slide 40
SAY: For a risk factor assessment to make a difference, all the risk factors identified in … Ensure that the care plan addresses all areas of risk.
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-131-section-7-a-table-10-11-12.pdf
January 01, 2008 - Table 10 – Analysis of Disparities in Readmission Risk … Hispanic 1.33 [1.20 – 1.48]
Other 1.08 [0.95 – 1.22]
Table 11 – Analysis of Disparities in Readmission Risk … 1.06 - 2.07]
Native American 1.26 [1.06 - 1.50]
Table 12 – Analysis of Disparities in Readmission Risk
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/CHIPRA202-Materials_IIIA.pdf
January 01, 2014 - to recommendations focused on global developmental
screening using tools that focus on identifying risk … CAHMI*
Follow-up for children at risk for delays:
proportion of children who were
determined to … to be at
significant risk for development, behavioral, or social delays who received some level of … Parent-reported quality of preventive care for children at-risk for
developmental delay. … to be at significant risk for development,
behavioral, or social delays who received some level of