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pbrn.ahrq.gov/teamstepps/lep/traintrainers/lepigstafftrain.html
October 01, 2020 - High-Risk Settings and Situations .
Added Risk for LEP Patients . … Ask participants: What are the risks in this situation? What was handled well? … Discussion:
What are the risks to the patient in this scenario?
What could go wrong? … I'm uncomfortable...This is a safety issue..." it means that we need to pause and make sure no safety risks … Team goals, plans, and risks—what is to be accomplished, who will do it, and what the potential risks
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pbrn.ahrq.gov/teamstepps/lep/handouts/lepcourseeval.html
December 01, 2012 - I improved my understanding of patient safety risks to LEP patients
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pbrn.ahrq.gov/teamstepps-program/curriculum/situation/tools/monitoring.html
June 01, 2023 - Cross-Monitoring
Ongoing cross‐monitoring of the care environment helps everyone recognize risks
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_safe-csection.docx
May 01, 2017 - Examples
Preoperative briefing
· The briefing reviews the plan ahead for patient care and the risks … It includes reviewing patient information, procedure, indications, risk, medical history, fetal status … Discovery form
· Root cause analysis
· Eindhoven model
· Failure mode and effects analysis
· Probabilistic risk … of transition communication techniques assures a shared mental model of plan of care and perceived risks … Patient and Family Engagement (CUSP Module)
Key Perinatal Safety Elements
Examples
Communicate risks
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pbrn.ahrq.gov/cpi/about/nac/pcortf-snac/rhodes.html
November 01, 2022 - research teams testing emergency department innovations in screening/intervening for health-related social risks
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/lepcourseeval.pdf
July 25, 2012 - I improved my understanding of patient safety risks to
LEP patients
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pbrn.ahrq.gov/patient-safety/settings/hospital/resource/about.html
December 01, 2017 - But there is only limited understanding of such risk factors currently. … Health Care Leaders and Professionals
Many individuals do not understand the benefits, harms, and risks … that hospitals and clinical teams can use to ensure that people understand the benefits, harms, and risks … Fall prevention involves managing a patient's underlying fall risk factors and optimizing the hospital's … These skin lesions bring pain, associated risk for serious infection, and increased health care utilization
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pbrn.ahrq.gov/patient-safety/patients-families/index.html
June 01, 2023 - five-step process for shared decisionmaking that includes exploring and comparing the benefits, harms, and risks … The Toolkit to Engage High-Risk Patients in Safe Transitions Across Ambulatory Settings
This toolkit … Research Summaries for Consumers
These free research summaries discuss the benefits and risks of different
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/tool_safe-oxytocin.docx
May 01, 2017 - of error.12
· The risks and benefits of low- versus. high-dose oxytocin protocols remain an active … The use of standard NICHD nomenclature17,18,19 reduces confusion and risk of error. … · Use unit-established process for conveying risks and benefits of oxytocin use to patient and family … Verifying and documenting indications for use (continued)
discussion with patient of risks and benefits … and documentation of the discussion about risks, benefits, and alternatives should be documented to
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pbrn.ahrq.gov/research/findings/making-healthcare-safer/index.html
July 01, 2023 - Health System , the seminal National Academy of Medicine report that elevated awareness of longstanding risks
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/clinicians-providers/iadapt/moreno.pdf
December 17, 2014 - school-level curriculum
to improve students’ health decision-making skills,
knowledge of heart disease risks … scientific decision-
making activities demonstrated knowledge gains
about cardiovascular disease and risk
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pbrn.ahrq.gov/antibiotic-use/long-term-care/improve/index.html
September 01, 2021 - techniques can help improve antibiotic use, as can fostering effective communication about the potential risks
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pbrn.ahrq.gov/diagnostic-safety/research/grants-2019.html
March 01, 2024 - combine adjudication data with data from Vizient to determine which specific factors contribute to risks … for diagnostic errors, and to use risk estimates to calculate incidence and impact of factors contributing … An expert-guided machine-learning approach to estimate the incidence, risk and harms associated with … To identify the risk factors associated with diagnostic delays for infectious diseases that are frequently
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pbrn.ahrq.gov/hai/tools/cauti-hospitals/index.html
March 01, 2018 - to create or enhance a culture of patient safety can significantly decrease rates of CAUTI and other risks
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pbrn.ahrq.gov/patient-safety/reports/safer-together.html
November 01, 2022 - Reducing preventable harm requires a total systems approach: a coordinated, proactive strategy in which risks
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pbrn.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/practices.html
January 01, 2013 - a system in place to ask the same key questions of each patient so that risks are not missed. … risks. … This includes planning for any risks found on the risk factor assessment tool, such as mobility challenges … for falls because the benefits outweigh the risks, but the important point is that fall risk was considered … The care plan helps all staff members to be aware of a patient's risks.
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pbrn.ahrq.gov/patient-safety/settings/long-term-care/index.html
September 01, 2021 - It is a customizable “train the trainer” program plus specialized tools to reduce risks to patient safety
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pbrn.ahrq.gov/news/newsroom/press-releases/nac-meeting-members.html
July 01, 2022 - Because of the continued risks of in-person meetings during the pandemic, the meeting will be available
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pbrn.ahrq.gov/sites/default/files/docs/AHRQ_PBRN_Webinar_IRB_Challenges_QI_Research_5.27.15.pdf
September 10, 2015 - – Unaware of enrollment
– Poor understanding of:
• benefits
• potential risks
• randomization … What are the risks, or bad things that might
happen to you if or when you join this study? … future patients
directly benefits a process, system or program;
might or might not benefit patients
Risks … may put subjects at risk does not increase risk to patients, with exception
of possible patients' privacy … methodology/design
• Fixed protocol with a rigid goal, methodology,
population, time period, etc.;
• Risks
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pbrn.ahrq.gov/funding/policies/nofoguidance/index.html
January 01, 2024 - Protection of Human Subjects
The AHRQ Informed Consent and Authorization Toolkit for Minimal Risk … Priorities include:
Research on patient safety
Identification of risks, hazards, and patient harm … patient safety practices) and the adaptation, refinement, and sustainment of those strategies to address risks … Patient characteristics that might influence the risk of experiencing a patient safety event, for example … to develop, implement, evaluate, and spread effective patient-centered models of care for people at risk