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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4p_combo_pdi02-pressureulcer-bestpractices.pdf
January 01, 2012 - equipment
and devices.1
• Pressure ulcer rates are high in children, particularly those with high-risk … from 2.4 to 7.7 per 1,000
pediatric discharges (across all children).2-4 In subgroups at particular risk … (3.5 times the odds of children without the complication), even after
adjusting for numerous other risk … documentation record for the completion of a
total skin assessment and risk assessment.11,12 … Risk assessment & prevention of
pressure ulcers 2011 supplement. Toronto, ON: RNAO; 2011.
11.
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pbrn.ahrq.gov/tools-and-resources/pbrn-literature/perceived-ethnic-discrimination-and-cigarette-smoking-examining
January 08, 2022 - Some sociodemographic and mood-related risk factors may confound the relationship of discrimination to … decision, differences, effects, electronic, factors, Men, Methods, New York, Research, Research Support, Risk … , Risk Factors, Role, Smoking, support, understanding, Universities
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pbrn.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/implementation.html
January 01, 2013 - patient's risk factors for falls to the admitting department. … Nurse:
Completes and documents fall risk assessments. … Reviews medications for fall risk and makes changes to medications as needed. … Fall risk factor report that summarizes which patients on the unit have specific risk factors. … First, consider how information about fall risks is conveyed in handing off patients to other units or
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4a_combo_psi03-pressureulcer-bestpractices.pdf
January 01, 2012 - Assessment at
Admission and Daily
Evaluate all patients for pressure ulcers and pressure
ulcer risk … (using Braden Scale or other tool) upon
admission and every 24 hours thereafter, using valid
risk … o Agrees on the use of a standard risk assessment tool (for example, Braden Scale);
facilities may … ulcer risk assessment will be used as the standard in your
organization. … Risk assessment & prevention of
pressure ulcers.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool3f.docx
January 29, 2013 - Orthostatic Vital Sign Measurement
Background: This tool can be used to identify orthostatic hypotension, a risk … When a patient is on a medication that may cause orthostasis and has other risk factors for falls. … Use this tool in conjunction with clinical assessment and a standard assessment of fall risk factors … (e.g., Tool 3H, “Morse Fall Scale for Identifying Fall Risk Factors, or Tool 3G, ‘STRATIFY Scale for … Identifying Fall Risk Factors”) to determine a patient’s risk factors for falls, and then plan care accordingly
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pbrn.ahrq.gov/teamstepps/instructor/essentials/implguide2.html
November 01, 2018 - Then mark with an "X" the risk points in the process where things could go wrong and lead to a recurrence … identify with arrows where in the process team strategies and tools might eliminate or mitigate the risk … Have other groups successfully used specific team tools to reduce similar process risk points? … Benefits outweigh risks
Evidence-based
Measurable
Desired result can be measured with objective … Incorporates redundancy and back-up systems to minimize risk of patient harm in event of error or process
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pbrn.ahrq.gov/news/blog/ahrqviews/delivery-primary-care.html
November 01, 2022 - 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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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheetinstructions.pdf
June 05, 2016 - In column E, “Volume of Cases at Risk,” indicate the annual volume of each PSI, IQI, and/or
PDI event … Patients who experience
adverse events often tend to have more comorbidities and other risk factors … Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
2 Tool C.1
costs and risk … To determine this number, for each PSI, IQI, and/or PDI, multiply
column E, “Volume of Cases at Risk … the best way by
which executives can review the execution of projects, identify gaps, and spot new risks
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pbrn.ahrq.gov/funding/grantee-profiles/grtprofile-fairbanks.html
December 01, 2023 - increase knowledge and create tools that help healthcare providers reduce patient safety events in high-risk … settings of care, where the complexity of the system and the fragility of the patients creates a greater risk … Continuing with his focus to improve patient safety in complex and high-risk healthcare environments, … grant to study and develop processes to boost decisionmaking and problem solving in a range of high-risk … Fairbanks describes, hospital EDs are high-risk, fast-paced environments involving coordination and shared
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pbrn.ahrq.gov/research/findings/making-healthcare-safer/comparison.html
September 01, 2022 - Health System , the seminal National Academy of Medicine report that elevated awareness of longstanding risks … Preventing Adverse Drug Events
Summary of Evidence
Update
(Not reviewed)
Protocols for High-Risk … MHS III (2020)
Safety Culture
(Not reviewed)
(Not reviewed)
Summary of Evidence
Alarm Risk … Miscommunications
(Not reviewed)
Summary of Evidence
(Not reviewed)
Identifying Patients at Risk
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/medread-tools.pdf
July 28, 2016 - Care Planning
This tool provides
discharge planners with a
set of prompts to identify
readmission risks … and to take
steps to ensure those risks are
addressed in the transitional
Day-to-day readmission … Description
This tool provides discharge planners with a set of prompts to identify readmission risks … and to
take steps to ensure those risks are addressed in the transitional care (discharge) plan. … Accessed July 28, 2016.
2
WHOLE-PERSON CARE TRANSITIONAL PLANNING TOOL
Readmission Risks and
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pbrn.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module1/mod1-facguide.html
March 01, 2017 - Slide 18: Understanding Risk and Human Behavior 1
Say:
Just Culture helps us understand risk and … At-risk behavior—Choosing to behave in a way that increases risk, where risk is not recognized or is … Slide 19: Managing Error and Risk 1
Say:
To improve outcomes, human error, at-risk behavior, and … At-risk behavior is an active choice to engage in risky activity through a belief that the risk was either … for healthy, risk-reducing choices.
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pbrn.ahrq.gov/news/newsroom/case-studies/201801.html
April 01, 2018 - Chris Myers, R.N., B.S.N., the hospital’s risk manager and patient safety officer, explained that use … Myers said AHRQ’s program emphasizes the importance of accurately assessing the risk of falls for patients … “There had been some confusion as to whether identifying patients as ‘low fall risk’ was actually the … most accurate risk level for most patients,” he explained.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4k_combo_psi14-dehiscence-bestpractices.pdf
May 20, 2016 - of stay, subsequent surgeries and incisional herniation.2,3
• Proper identification of patients at risk … Though many risk factors are non-modifiable, there are factors that can be
addressed by hospitals, such … Determine risk factors for postoperative wound dehiscence
and identify patients at risk.1-3,7
Reduce … • Educate patient about risk factors of noncompliance with postoperative instructions. … Abdominal wound dehiscence in adults:
development and validation of a risk model.
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pbrn.ahrq.gov/health-literacy/professional-training/shared-decision/tool/resource-9.html
September 01, 2020 - Improves accurate risk perceptions of possible benefits and harms among patients. … of conditions, patients are less likely to opt for invasive procedures when fully informed about the risks … randomized trial conducted in the Netherlands that addressed shared decisionmaking for women at high risk
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pbrn.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/prp/prp-wound-care.pdf
September 17, 2020 - autologous PRP demonstrated a statistically
significant increase in complete wound closure or healing (Relative … We extracted or calculated relative risk
(RR) and corresponding 95 percent confidence intervals for … or unclear risk of bias. … small (<300) or the confidence intervals included substantial benefits and harms
(defined as 0.25 relative … risk reduction or increase).
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pbrn.ahrq.gov/funding/grantee-profiles/grtprofile-dykes.html
September 01, 2022 - 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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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module5/module5_slides_fallprev.pptx
December 03, 2012 - Performance of care planning that addresses each risk factor identified during fall risk factor assessment … Ensure that known risk factors for falls are assessed. … Page 78
‹#›
Care Planning Assessment
All risk factors identified on the fall risk factor assessment … that care plans address all areas of risk.
‹#›
Assessment of Care Plan Performance
See the sample … A care plan addressing every deficit on the fall risk factor assessment has been developed and is being
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module3/putoolkit_module3_tools.docx
August 31, 2017 - Generally, a score of 18 or less indicates at-risk status. … factors and 1-3 for the last risk factor. … Generally, a score of 14 or less indicates at-risk status. … Use: Individualize the care plan to address the needs of at-risk patients. … PRESSURE ULCER RISK ASSESSMENT CASE STUDY
Mr.
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pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
August 01, 2022 - Individual is not educated about potential risk and sees no value in established policies to prevent … Manage by:
Removing incentives for at-risk behaviors. … Educate about potential risks.
Redesign of system factors. … Risk management. … J Healthc Risk Manag. 2013;33(2):11-20.
What are the Outputs from the Solutions Meeting?