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pbrn.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-portfolios-summary-profile-2014.pdf
January 01, 2014 - The term safety refers to reducing
risk from harm and injury, whereas the term quality
suggests striving … PSOs aim to help providers detect and reduce risks and
hazards associated with their delivery of care … reporting, such as
sharing examples of how the event reports led to changes
that reduced health care risks
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pbrn.ahrq.gov/news/newsletters/e-newsletter/899.html
February 01, 2024 - Newsletter
AHRQ News Now
Events
Heart Failure Patients’ Risk … [PDF, 9 MB])
Today's Headlines:
Heart Failure Patients’ Risk of Adverse Events Higher in Poor-Performing … Heart Failure Patients’ Risk of Adverse Events Higher in Poor-Performing Hospitals
Patients with heart … hospitals with higher 30-day readmission rates and deaths from all causes have a 24 percent higher risk … failure admitted to hospitals that perform poorly on mortality and readmission measures have higher risk
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/shareddecisionmaking/tools/tool-7/share-tool7.pdf
April 01, 2014 - aids, treatment summaries, and educational materials that have
culturally relevant descriptions of risks
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pbrn.ahrq.gov/health-literacy/professional-training/shared-decision/tool/resource-3.html
September 01, 2020 - statute, regulation, and case law, the informed consent process requires explanations of the benefits and risks … Make sure the interpreter understands the information, especially if the patient's life may be at risk … When a minor child interprets, the child is in a very vulnerable position and the practice is at risk
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pbrn.ahrq.gov/evidencenow/projects/heart-health/evidence/cholesterol.html
March 01, 2021 - Management Evidence and Resources
People with elevated levels of cholesterol are at increased risk … to manage blood cholesterol can reduce the chance of having a heart attack for people at increased risk … factor and an increased risk of a CVD event (>=10% in 10 years). … The USPSTF recommended discussing statin use in similar patients with more moderate risk of a CVD event … All patients at high risk should receive a high- or moderate-intensity statin unless contraindicated
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pbrn.ahrq.gov/hai/cusp/modules/apply/ac-cusp.html
December 01, 2012 - Understanding Risk and Human Behavior Slide 7. Managing Error and Risk Slide 8. … At-risk behavior—Choosing to behave in a way that increases risk, where risk is not recognized or is … Managing Error and Risk
Say:
To improve outcomes, human error, at-risk behavior, and reckless … To achieve optimal outcomes, organizations must design robust systems that minimize risks. … It is critical to reinforce behaviors that will reduce risk and deter behaviors that increase risk.
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pbrn.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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pbrn.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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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/CombatCare.pdf
March 18, 2014 - Although not life threatening, the error placed the patient at
unnecessary risk, delayed his disposition … Instructor Comments
This scenario illustrates the potential risks of low workload. … Instructor Comments
This scenario illustrates the potential risks of low workload.
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pbrn.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu3a.html
October 01, 2014 - Once risk assessment has helped identify patient risk factors, it is important to match care planning … This includes planning for any risks found on the risk assessment tool, such as nutrition, activity, … This means addressing at-risk scores on each subscale, as well as other risk factors not quantified on … Any area of risk should have a corresponding plan of care regardless of the overall risk assessment … is addressing this risk.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module3/module3_pu-bestpractices.docx
June 12, 2018 - up with a risk assessment score? … scores of the risk assessment tool, but also other factors placing the patient at risk. … ASK: How do you indicate your patients’ risk status? How is risk identified at shift handoff? … prevent pressure injuries is to create a care plan that is responsive to the patient’s pressure injury risks … this risk.
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pbrn.ahrq.gov/teamstepps/lep/hospitalguide/lephospitalguide.html
December 01, 2012 - Improve patient safety systems to capture root causes and risk factors. … Return to Contents
Slide 19: Specific Recommendations for High-Risk Scenarios
High-risk clinical … Resources to address these high-risk scenarios should be a priority. … To address high-risk scenarios:
Require presence of qualified interpreters. … of activities and strategies can help hospital leaders initiate an agenda to address patient safety risks
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pbrn.ahrq.gov/hai/tools/ambulatory-care/safe-transitions.html
December 01, 2017 - Telemedicine
Universal ICU Decolonization Protocol
Toolkit to Engage High-Risk … The Toolkit to Engage High-Risk Patients in Safe Transitions Across Ambulatory Settings ( PDF , 1.36 … 2017
Page originally created December 2017
Internet Citation: Toolkit to Engage High-Risk
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pbrn.ahrq.gov/tools-and-resources/pbrn-literature/diagnostic-accuracy-gail-model-black-womens-health-study
January 07, 2022 - Abstract: The Gail model is used to predict the risk of breast cancer in women of diverse race/ethnic … Risk profiles were derived via a self reported questionnaire at the time of enrollment into the BWHS … The study of 725 breast cancer cases and 725 controls revealed that the 5-year risk of breast cancer … Based on the GM-B, the 5-year risk of breast cancer ranged from 0.2% to 8.7% among cases and 0.2% to … , Risk Assessment, ROC Curve, Standards, support, Universities, women, Women's Health
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/apply/facapplycusp.docx
September 04, 2012 - behavior—Choosing to behave in a way that increases risk, where risk is not recognized or is mistakenly … At-risk behavior is an active choice to engage in risky activity through a belief that the risk was either … To achieve optimal outcomes, organizations must design robust systems that minimize risks. … It is critical to reinforce behaviors that will reduce risk and deter behaviors that increase risk. … for healthy, risk-reducing choices.
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pbrn.ahrq.gov/news/newsroom/case-studies/202301.html
March 01, 2023 - Department of Veterans Affairs' national Hypoglycemic Safety Initiative to help high-risk diabetes patients … “About half of our veterans with diabetes—around 500 patients—are at high risk for hypoglycemia,” said … “For these patients, general efforts to lower A1C levels only increase their risk for hypoglycemia. … To reduce the risk of hypoglycemia in these patients, Dr. … clinical pharmacy specialists, to discuss reducing or changing their medication to reduce their risk
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pbrn.ahrq.gov/tools-and-resources/pbrn-literature/vitamin-d-exposure-during-pregnancy-not-early-childhood
January 04, 2022 - Vitamin D exposure during pregnancy, but not early childhood, is associated with risk … history, hospital, knowledge, Medicine, Odds Ratio, Pregnancy, primary care, regression, Research, Risk
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pbrn.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/ldu-safety-slides.html
July 01, 2023 - Rationale for Use of Checklists 1-4
Checklists help to facilitate safety in high-complexity, high-risk … Review plan for patient care, risks, or concerns.
Typically led by the obstetrician/surgeon. … Risk.
Medical history.
Fetal status.
Type of anesthesia. … Slide 21: Key Safety Elements: Standardize When Possible
Use routine and standardized hemorrhage risk … 32: Key Safety Elements: Teamwork Training
Have situational awareness around maternal and fetal risks
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pbrn.ahrq.gov/patient-safety/reports/advances-new-directions/index.html
July 01, 2022 - It includes articles on reporting systems, risk assessment, safety culture, medical simulation, patient … Risk Assessment
Risk-Based Patient Safety Metrics ( PDF , 614 KB ) Matthew C. … Using a Computerized Fall Risk Assessment Process to Tailor Interventions in Acute Care ( PDF , 338 … Risk Reduction and Systematic Error Management: Standardization of the Pediatric Chemotherapy Process … Failure Mode and Effects Analysis Based on In-Situ Simulations: A Methodology to Improve Understanding of Risks
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pbrn.ahrq.gov/evidencenow/projects/heart-health/evidence/blood-pressure.html
March 01, 2021 - Blood Pressure Control Evidence and Resources
High blood pressure is a major risk … Blood Pressure
This in-depth patient education booklet explains high blood pressure and the potential risks