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pbrn.ahrq.gov/patient-safety/resources/learning-lab/transdisciplinary-learning-long-desc.html
June 01, 2020 - and implement an indicator of unit-level stress in an engineered care system to predict and mitigate risk … J Patient Saf Risk Manage 2019 Dec 10. https://journals.sagepub.com/doi/abs/10.1177/2516043519893228. … J Patient Saf Risk Manage 2019 Dec 10.
Matthews S, et al. … J Patient Saf Risk Manage 2018;23(4):155-66.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/psml-planning-grants-final-report.pdf
May 01, 2016 - Risk can be minimized with solutions
that integrate medication risk management efforts into transitional … risk management efforts into
transitional care models. … to enhance
communication between patients and families and their care providers, thus reducing the risks … Modeling Risk and Reducing Liability Through Better
Communication and Teamwork. … examined, 78 percent involved an
element of informed consent or SDM, primarily in the areas of treatment risks
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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?
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pbrn.ahrq.gov/talkingquality/measures/understand/patient-comments.html
February 01, 2016 - J Risk Uncertain 1997;14(3):235–57. [4] Schwartz LM, Woloshin S, Black WC, Welch HG. … What does it mean to understand a risk? Evaluating risk comprehension. … Risk as feelings. Psychol Bull 2001 Mar;127(2):267-86. [7] Redelmeier DA, Rozin P, Kahneman D.
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pbrn.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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pbrn.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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pbrn.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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pbrn.ahrq.gov/opioids/health-systems-research.html
July 01, 2021 - approaches to improve the use of screening for unhealthy alcohol use, brief intervention for those at risk … opioids and other substance use disorders
Toward Safer Opioid Prescribing for Chronic Pain in High Risk … Risk of Acute Asthma Associated With the Pediatric Use of Opioids. … Prescription Opioid Use Trajectories and Risk Factors Associated with Opioid-Related Hospitalizations
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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/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/patient-safety/settings/hospital/resource/pressureulcer/tool/put5.html
October 01, 2014 - Performance of standardized risk assessment within 24 hours of admission. … Risk assessment is the cornerstone of prevention. … Ensure that a standardized risk assessment was performed within 24 hours of admission. … For risk assessment to make a difference, all areas of risk identified on the standardized risk assessment … Ensure that the care plans address all areas of risk.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/evidencenow/building-capacity/EvidenceNOW-BSC-AL-profile.pdf
September 01, 2021 - Consortium for Southeast
Healthcare Quality
Project Period:
2021-2023
Supporting cardiovascular risk … improvement (QI) capacity and improve cardiovascular health through
implementation of evidence-based, risk … The project seeks to
coordinate cardiovascular risk reduction efforts across the state to create efficiency … care practices and non-traditional
providers of primary care across the state in a Cardiovascular
Risk … The evaluation will assess the creation and utility
of the Cardiovascular Risk Reduction Network of
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pbrn.ahrq.gov/sites/default/files/publications/files/universalicu.pdf
September 01, 2013 - The benefits and potential risks should be weighed with any strategy. … of infection during the high-risk period
of critical care. … Goal is to prevent MRSA during high-risk periods (ICU stays, post-op). … Product Safety and Adverse Events
Chlorhexidine (CHG) Risk
The risks associated with the use … Nasal Mupirocin Risk
The risks associated with use of nasal mupirocin include mild side effects of
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pbrn.ahrq.gov/hai/cusp/videos/index.html
September 01, 2019 - and Independent Input Identify Your Unit's Safety Issues Develop a Plan of Action How Will You Know Risk … Identifying Contributing Factors What Will You Do to Reduce the Risk of Recurrence?
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pbrn.ahrq.gov/talkingquality/measures/types.html
July 01, 2015 - Risk-adjustment methods—mathematical models that correct for differing characteristics within a population … However, the science of risk adjustment is still evolving. … Experts acknowledge that better risk-adjustment methods are needed to minimize the reporting of misleading
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b2a_combo_ratesgenbysas.pdf
March 01, 2016 - Note: The current version of the AHRQ QI software does not have risk-adjustment capabilities
when using … However, this tool includes information about risk adjustment that will
be relevant when looking at … Identify populations at risk.
3. Calculate observed (raw) indicator rates.
4. … Risk adjust the indicator rates (where applicable).
5. … SAS*
PSI_PROVIDER_2
.SAS*
PDI_PROVIDER_2
.SAS*
Calculates expected rates, risk-
adjusted rates,
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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/patient-safety/settings/labor-delivery/perinatal-care/about.html
July 01, 2023 - In addition to communication failures, patients on labor and delivery (L&D) units are at risk of medication … use of inappropriate interventions, or interventions provided in an unsafe manner, also increases the risk
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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/patient-safety/settings/hospital/fall-prevention/webinar/slides.html
June 01, 2018 - Slide 18
Challenge
Inadequate Risk Assessments and Reassessments
Image of young man with clipboard … and image of rubber stamp
Slide 19
Opportunity
Accurate and effective risk assessments
Employing … critical thinking and clinical judgment
Consistency in approach
Identifying and communicating risk … possible time
Slide 20
Tools
Morse Fall Scale (3H)
STRATIFY Scale (3G)
Medication Fall Risk … target education to address gaps in staff knowledge
Environmental safety
Medications associated with risk