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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_lowvision.pdf
May 01, 2017 - QI and patient safety during a time when
they experienced an increase in patient load and higher
risk … for more high-risk patients than ever before, so it is even
more crucial that we do things right…it’ … It is a safe way to deal with high-risk situations. … This variation created a risk
of both time lags in patient care and miscommunication
among the care … However, as one project leader soon recognized, “If
we’re going to do a [hemorrhage] risk assessment
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_fullcolor.pdf
May 01, 2017 - QI and patient safety during a time when
they experienced an increase in patient load and higher
risk … for more high-risk patients than ever before, so it is even
more crucial that we do things right…it’ … It is a safe way to deal with high-risk situations. … This variation created a risk
of both time lags in patient care and miscommunication
among the care … However, as one project leader soon recognized, “If
we’re going to do a [hemorrhage] risk assessment
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/lab-testiing/lab-testing-toolkit.pdf
December 01, 2017 - Assessing Risk in Testing
We know that:
• The risk of an event is related to its frequency and the … • Balancing these two aspects of risk can be challenging. … • It is important to stay focused on office systems in managing risk. … Results
• The highest scores for “office total” show areas where staff have identified the
greatest risks … do not eliminate all errors.
• A failure to monitor automated processes may introduce patient safety risks
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule8.pptx
March 28, 2006 - We're all at risk for this. … direction
Allow others to find their own team-driven solutions
Encourage others to speak up and take risks … They should also encourage risk-taking and nontraditional ideas, activities, and actions. … Encourage people to take risks. Affirm and refine the vision. Make room for others' ideas.
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ahrqpubs.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module3/mod3-facguide.html
March 01, 2017 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … To achieve optimal outcomes, organizations must design systems that minimize risks. … It's important to reinforce behaviors that reduce risk and deter behaviors that increase risk. … All humans make mistakes, and it is important to differentiate between human error and at-risk behavior
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4_combo_bestpracticescover.pdf
June 05, 2016 - Rate―Injury to Neonate: The existing literature on birth trauma
and injury to the neonate suggests multiple risk … Given this heterogeneity, creating one best practices form to address
the various risk factors would
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ahrqpubs.ahrq.gov/hai/cusp/modules/patient-family-engagement/notes.html
September 01, 2013 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … requires successful transfer of information between clinicians and the patient and family to reduce the risk … Reduces risk and liability. … policies and procedures for actions to take after an adverse event occurs, and most involve working with a risk … Providers report the incident to the unit manager and the risk management department following the hospital's
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/labordel.pdf
March 18, 2014 - communication techniques taught in this module could have avoided placing this
patient at unnecessary risk … s unfolding event, no one assumes leadership for the case and the patient is
placed at unnecessary risk … At exactly that moment, the Triage nurse receives a call that a high-
risk patient in acute distress … This high-risk
patient ties up three nurses, two residents, and a covering attending obstetrician for … Instructor Comments
In this situation, the RN team leader becomes aware of a potential risk for the
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ahrqpubs.ahrq.gov/cpi/about/impact/index.html
April 01, 2017 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … Hospital-acquired conditions have relatively high mortality risk and include central line-associated … Preventing central line-associated blood stream infections, the top-ranked mortality risk among all hospital-acquired
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/clabsitools/clabsitoolsap5.doc
December 11, 2012 - , eye protection
· Assistant: Cap, mask, isolation gown and gloves, eye protection (if at risk
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/shareddecisionmaking/tools/tool-4/share-tool4.pdf
April 01, 2014 - Fill out complex forms
› Find providers and services
› Share their health history
› Understand risk … chronic illness
› Skip needed tests
› Underuse preventive health care
Some groups are at higher risk
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/spread/spreadnotes.docx
August 28, 2012 - Having the Newborn Critical Care Center complete a falls risk assessment for each patient for each shift … , quantitative measures to evaluate can include the falls rate and the number of patients with fall risk … Solutions that are simple and designed with very little risk of failure contribute to the success of
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/ahrq-network-factsheet.pdf
February 01, 2022 - especially vulnerable, and their reliance
on nursing home staff put these essential workers at high risk
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/webinars/webinar6_falls_sustainingpractices.pdf
January 01, 2013 - specific
interventions
for fallers
Examples of Process Measures
Percentage of—
• Patients at risk … – For instance, reward unit staff the first time they
complete a fall risk assessment form correctly
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/evidencenow/cooperatives/evidencenow-executive-summary-midwest.pdf
November 01, 2017 - they need to help their patients adopt the
ABCS of cardiovascular disease prevention: Aspirin in high-risk … SMART: Behavioral Risk Factor Surveillance System
2 City and County Data. 2013.2 Health Resources and
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/evidencenow/cooperatives/evidencenow-executive-summary-northwest.pdf
November 01, 2017 - they need to help their patients adopt the
ABCS of cardiovascular disease prevention: Aspirin in high-risk … educational outreach
intervention learned about team-based implementation
of a cardiovascular disease risk
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/evidencenow/cooperatives/evidencenow-executive-summary-va.pdf
November 01, 2017 - they need to help their patients adopt the
ABCS of cardiovascular disease prevention: Aspirin in high-risk … Between Practice Ownership or
Affiliation With Baseline Performance on Addressing
Cardiovascular Risk
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ahrqpubs.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/urine-culturing/antibiotic-stewardship/part-2-slides.html
February 01, 2019 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … Antibiotics can cause harm to residents
High risk of side effects and adverse events. … Major risk factor for Clostridium difficile infection.
Driver of antibiotic resistance.
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ahrqpubs.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/mod4-facguide.html
March 01, 2017 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … during a change of shift report, vital pieces of information can be omitted, placing the resident at risk … For example, they might discuss the resident's decreasing mobility and the risk for falls. … has policies and procedures to follow after an adverse event occurs, and most involve working with a risk … Providers report the incident to the unit manager, resident's medical care provider, and the risk management
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange_slides.pptx
June 16, 2017 - injuries.
14
14
Toolkit Approach
The Toolkit includes accurate, evidence-based, and effective risk … Risk identification and communication at the earliest possible time.
15
Toolkit Approach
The Toolkit … focuses on optimizing effectiveness of interventions by:
Tailoring interventions to address individual risk