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pbrn.ahrq.gov/funding/grantee-profiles/grtprofile-huang.html
December 01, 2023 - If a person is colonized with MRSA, they have an increased risk of developing a MRSA infection and also … Removing MRSA from the patient cuts the risk of infection and transmission of the germ to other people … nursing homes because residents are older and more prone to having health conditions that increase their risk
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pbrn.ahrq.gov/funding/grantee-profiles/grtprofile-walsh.html
October 01, 2023 - Children with cancer are at particularly high risk for errors due to weight-based dosing calculations … contrast dye or nonsteroidal anti-inflammatory drugs, can cause acute kidney injury, which increases the risk … of mortality, length of hospital stay, and long-term risk of developing chronic kidney disease.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module1/module1_slides_fallprev.pptx
June 16, 2017 - Identifying and communicating risk at the earliest possible time.
‹#›
14
Toolkit Approach
The Toolkit … on optimizing the effectiveness of interventions by:
Tailoring interventions to address individual risk … (3-12/05)
Added Alert re-
meds to Scale
(11-12/05)
Developed Education
Brochure on meds
and fall risk … 05)
Started AARs
(safety
huddles) on
test units 10-
12/06
Teachback
w/pts 11/06
Put pts on high risk … ,
Morse score > 50, on
anticoagulants, low
platelets 12/06
Use yellow wrist bands
on high falls risk
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pbrn.ahrq.gov/evidencenow/tools/index.html
January 01, 2023 - New Cardiovascular Disease Risk Guide! … Learn how to integrate CVD risk calculation into primary care.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module2/module2_slides_fallprev.pptx
August 24, 2017 - services staff
Facilities engineer
Managers
Senior manager
Quality improvement/safety/risk … Determine who will complete the fall risk factor assessment on admission. Tool 4A. … Cathy April √
Tool 4C Assess Staff Education and Training Peggy and Jim April √
Determine How Risk … Team June √
Get Team buy-in on who does risk assessment and when (Nursing/4 hours). … Determine who will complete the fall risk factor assessment on admission. Tool 4A.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/topics/pridx-framework.pdf
July 05, 2023 - The value of
level 1 lies in identifying potential high-risk focus areas for
health care organizations … For example, placing pro-
viders at risk of reduced payments (i.e., penalties) vs. op-
portunities for … Additional
examples could be developed and mapped into to
determine the impact and tradeoffs of provider risks … This is where payers can shift more risk and
accountability to providers because it will be supported … Additional
work will be needed to study if any of these payment levers
increase the risk of burnout and
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pbrn.ahrq.gov/learning-health-systems/exploring-needs.html
September 01, 2022 - Identify Persons Who Are Frail
Frailty increases a person’s risk for functional impairment and cognitive … Identifying frailty and functional disability plays an important role in informing clinical care, risk-adjustment … Risk stratification developers may integrate EFI in their model development process, and population health
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pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module9.pptx
March 07, 2019 - 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. … solutions; encouraging people to speak up, even if they have differing views; encouraging people to take risks
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module5/module5_fall-prevention.docx
June 30, 2017 - When falls occur with assistance, it suggests that staff have identified at-risk patients and are in … Accurately completing the fall risk factor assessment within 24 hours of admission.
2. … Putting appropriate care planning in place that addresses each risk factor identified during fall risk … Slide 41
SAY: For risk factor assessment to make a difference, all risk factors identified on the risk … Ensure that the care plans address all areas of risk.
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pbrn.ahrq.gov/health-literacy/about/index.html
January 01, 2024 - Personal health literacy is a social risk. … Library of Medicine)
Plain Language: Getting Started or Brushing Up (National Institutes of Health)
Risk
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pbrn.ahrq.gov/funding/grantee-profiles/grtprofile-hernandez-boussard.html
April 01, 2024 - and that national trends for surgical subgroups often were not available, putting patient safety at risk … teams in the process of algorithm development and ensuring that race is not used as a proxy for actual risk … Her research focuses on older patients and aims to mitigate the risk of adverse outcomes related to postoperative
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pbrn.ahrq.gov/teamstepps-program/curriculum/mutual/tools/task.html
May 01, 2023 - Teams are at risk whenever they are over- or underloaded. The reason? … Task assistance rebalances the workloads of team members to reduce this risk. … Vulnerability to error is increased when people are under stress, are in high-risk situations, and are
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module1/module1_fall-prevention.docx
March 01, 2013 - Risk assessments are most effective when increased risk for a fall is identified and communicated early … They gave an update on the risk assessment process changes. … The staff are transitioning to risk-based assessment and interventions tied to each identified risk factor … Before they used more of a definitional risk-based assessment and interventions. … For example, are staff individualizing care plans according to risk factors found on risk assessment?
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pbrn.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-1/guide.html
September 01, 2017 - Risk assessments are most effective when increased risk for a fall is identified and communicated early … They gave an update on the risk assessment process changes. … The staff are transitioning to risk-based assessment and interventions tied to each identified risk factor … Before they used more of a definitional risk-based assessment and interventions. … For example, are staff individualizing care plans according to risk factors found on risk assessment?
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pbrn.ahrq.gov/sdoh/health-systems-research.html
December 01, 2022 - , SDOH, and community services to create actionable dashboards to support better management of high-risk … Comparing health care system and physician practice influences on social risk screening . … This study examined the association of multilevel organizational capabilities and adoption of social risk
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pbrn.ahrq.gov/health-literacy/research/index.html
January 01, 2024 - Opportunities
Tools and Data for Researchers
Informed Consent and Authorization Toolkit for Minimal Risk … Research
The Informed Consent and Authorization Toolkit for Minimal Risk Research toolkit helps
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pbrn.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-5/guide.html
September 01, 2017 - When falls occur with assistance, it suggests that staff have identified at-risk patients and are in … Putting appropriate care planning in place that addresses each risk factor identified during fall risk … Slide 41
Say: For risk factor assessment to make a difference, all risk factors identified … on the risk factor assessment need to be addressed in the care plans. … Ensure that the care plans address all areas of risk.
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pbrn.ahrq.gov/hai/cusp/modules/index.html
August 01, 2019 - identify recurring negative events in your system and apply CUSP and Sensemaking tools to help reduce the risk … Toolkit introduces Just Culture principles, which emphasize shared accountability and attitudes towards risk
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pbrn.ahrq.gov/patient-safety/settings/hospital/resource/qitool/webinar080116/index.html
December 01, 2017 - Area-level indicators
Risk-adjusted (age, sex,poverty)
*Not included in the AHRQ QI Toolkit
Slide … Pressure Ulcer Risk 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 assessment, with results documented in the patient's chart. … Slide 67
Looking Back and Looking Forward
Retrospective Reviews
Appropriate Risk Assessment
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pbrn.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/index.html
February 01, 2024 - Fall prevention involves managing a patient's underlying fall risk factors and optimizing the hospital's … What is a standardized assessment of risk factors for falls, and how should this assessment be conducted … How should identified risk factors be used for fall prevention care planning?
3.5.