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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module3/module3_slides_best-practices.pptx
June 16, 2017 - Fall Risk Assessment
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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
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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.qualitymeasures.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.qualitymeasures.ahrq.gov/health-literacy/professional-training/lepguide/app-f.html
September 01, 2020 - Improve Safety for LEP Patients: Address (continued) Slide 19: Specific Recommendations for High-Risk … Patient Safety, Quality, and Cost Drivers
Greater risk of line infections, surgical infections, falls … Specific Recommendations for High-Risk Scenarios
Certain high-risk clinical situations need immediate … activities and strategies that can help hospital leaders initiate an agenda to address patient safety risks … Legal Rev Commentary Suppl Healthcare Risk Manage . 2003(May 1'3).
2011 Comprehensive Accreditation
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-121-technicalspecs.pdf
January 31, 2020 - Technical Specifications: High-Risk Deliveries at Facilities with 24/7 In-House Physician Coverage Dedicated … Description
Reporting on the extent to which high risk women are delivered at facilities
with 24/7 … Identify those deliveries associated with high risk
conditions
1. … Maternal record: High Risk Diagnoses
2. Maternal record: Complicated Delivery
3. … These are considered women in potential need of high risk services
(“high risk” for short)
Step 4
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www.qualitymeasures.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-3/slides.html
September 01, 2017 - Slide 14: Fall Risk Assessment
Slide 15: Step 1: Fall Risk Screening/Assessment
Use a reliable … Add unit-level risk factors as needed. … Other risks:
IV pole.
Orthostatic hypotension.
Oxygen tubing. … Image: Paper labeled “fall risk.” … Choose a tool for assessing risk factors.
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www.qualitymeasures.ahrq.gov/talkingquality/explain/communicate/reason.html
November 01, 2018 - In general, advertisers and marketers believe that messages that emphasize risks people face are more … hospital information found that when quality information is framed in terms of helping people avoid risks … hospital, people understand it better, value it more, and are more willing to make tradeoffs to avoid risk … home data at all. [3]
These findings suggest that when people need to be reminded that there is a risk … because many people believe they all offer about the same quality of care and don’t think about the risks
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www.qualitymeasures.ahrq.gov/research/findings/final-reports/ssi/ssiapt.html
April 01, 2018 - Initial Risk Factors
Appendix J. Additional Risk Factors
Appendix K. … Final Risk Factors
Appendix L. … SIR predicted infection risk better than the basic risk index for the procedures that we examined. … We hypothesize that improved risk adjustment is due to consideration of these extra risk factors. … Given its inferior risk stratification performance, the basic risk index should no longer be used when
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/chipra_1415-p009-5-ef.pdf
May 01, 2013 - ● Rates of cesarean delivery for women without other risk factors can be influenced by the number … College of Obstetricians and Gynecologists
(ACOG).7 The 2013 ACOG Committee Opinion cites evidence of risks … than vaginal birth, including risks to mothers and children, and
only 4 dimensions where vaginal birth … had greater risk than cesarean delivery.8
Advantages of the Measure
● This measure is specified to … Comparing risks of cesarean and vaginal birth to mothers, babies, and
future reproductive capacity: a
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/webinars/webinar5_falls_measuringratespractices.pdf
January 01, 2013 - 5
Types of Falls
Accidental falls
May be caused by—
• Extrinsic environmental risk factors or … preventability.
6
Types of Falls
Anticipated physiological falls
May be caused by—
• Known fall risks … Falls
Unanticipated physiological falls
May be caused by—
• Factors associated with unknown fall risks … • Make sure the individualized care plan is
tailored to the patient’s fall risk factors. … Factors
– Tool 3H: Morse Fall Scale for Identifying Fall Risk Factors
– Tool 3I: Medication Fall Risk
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-0232-table2.pdf
January 01, 2011 - Level of
Evidence
(USPSTF
Ranking*)
Citations
Expert
recommendation
Hypertension is a risk … particularly hypertension), and early deaths
resulting from heart disease or stroke, to
assess the risks … Risk factors and risk behaviors accelerate the
development of atherosclerosis, and risk
reduction delays … culminates in thrombosis,
III Expert Panel on Integrated
Guidelines for Cardiovascular
Health and Risk … on Integrated Guidelines for
Cardiovascular Health and
Risk Reduction in Children
and Adolescents:
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www.qualitymeasures.ahrq.gov/talkingquality/translate/scores/adjustment-scoring.html
January 01, 2023 - of the patient population, specifically whether—as a group—patients in one facility are at greater risk … Risk adjustment is a complex statistical enterprise. … [1] [2]
Why adjust for risks or severity? … Most common risk adjustments—for age, prior medical history, or comorbidities—are considered a good idea … Risk Adjustment for pediatric quality indicators.
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www.qualitymeasures.ahrq.gov/es/hai/universal-icu-decolonization/universal-icu-apg.html
September 01, 2013 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … Safety and Adverse Events
Chlorhexidine (CHG) Risk
The risks associated with the use … chest; swelling of the mouth, face, lips, or tongue), but it has occurred so rarely that the actual risk … Nasal Mupirocin Risk
The risks associated with use of nasal mupirocin include mild side effects of
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www.qualitymeasures.ahrq.gov/hai/universal-icu-decolonization/universal-icu-apg.html
September 01, 2013 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … Safety and Adverse Events
Chlorhexidine (CHG) Risk
The risks associated with the use … chest; swelling of the mouth, face, lips, or tongue), but it has occurred so rarely that the actual risk … Nasal Mupirocin Risk
The risks associated with use of nasal mupirocin include mild side effects of
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-0122-technical-specs.pdf
February 05, 2020 - High-Risk Deliveries at Facilities with 24/7 In-House Blood Banking/Transfusion Services - Technical … Description
Reporting on the extent to which high risk women are delivered at facilities
with 24/ … Identify those deliveries associated with high risk
conditions
1. … Maternal record: High Risk Diagnoses
2. Maternal record: Complicated Delivery
3. … These are considered women in potential need of high risk services
(“high risk” for short)
Step 4
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/diagnostic-toolkit/03-diagnostic-safety-infographic.pdf
August 01, 2021 - Improve
Diagnostic Safety strategy.
1- CRICO Strategies, 2014 Annual Benchmarking Report: Malpractice Risks … Medical Institutions; 2015. https://
www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-the-Diagnostic-Process … To Improve Diagnostic Safety
https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-the-Diagnostic-Process
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www.qualitymeasures.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?
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www.qualitymeasures.ahrq.gov/research/findings/final-reports/ssi/ssi5.html
April 01, 2018 - Initial Risk Factors
Appendix J. Additional Risk Factors
Appendix K. … Final Risk Factors
Appendix L. … eight additional potential risk factors. … Thus, 41 potential risk factors were included.
E3.5.1. … different in the list of significant risk factors.
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www.qualitymeasures.ahrq.gov/hai/tools/cauti-hospitals/toolkit-impl.html
October 01, 2020 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … 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 … 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 ( Microsoft
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www.qualitymeasures.ahrq.gov/health-literacy/professional-training/informed-choice.html
May 01, 2023 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … Literacy and Cultural Competence updates
Many individuals do not understand the benefits, harms, and risks … that hospitals and clinical teams can use to ensure that people understand the benefits, harms, and risks … presenting choices comprehensively, engaging patients and families, and explaining benefits, harms, and risks … University Health System Used AHRQ Tools
The AHRQ Informed Consent and Authorization Toolkit for Minimal Risk
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www.qualitymeasures.ahrq.gov/news/newsletters/e-newsletter/index.html
April 23, 2024 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … Relationship Between Electronic Nicotine Use and General Health
February 27, 2024
Bleeding Risks … Catalyze Staff Improvement and Bolster Survey Scores
February 6, 2024
Heart Failure Patients’ Risk … in Training for Learning Health Systems Scientists
January 16, 2024
Researchers Identify Risk … Related to Falls
October 17, 2023
New Data Resources Provide Insights Into Patient Safety Risks