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pcmh.ahrq.gov/teamstepps-program/curriculum/situation/tools/safe.html
June 01, 2023 - attention to underlying causes that may explain concerning behaviors or provide alerts to potential risks
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pcmh.ahrq.gov/cpi/about/otherwebsites/pso.ahrq.gov/index.html
August 01, 2022 - care organizations can voluntarily report, aggregate, and analyze data, with the goal of reducing the risks
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pcmh.ahrq.gov/talkingquality/assess/recommended-reading.html
May 01, 2019 - Aims, benefits and risks of consumer information initiatives.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/patient-safety-technology-resources.pdf
May 01, 2023 - Organizations (and perhaps
health IT technology developers, industry professional associations, and risk … Rather, the list reflects ECRI’s judgment about which risks should receive
priority now. … All the items on the list represent problems that can be avoided or risks that can be minimized
through … provided with the full article,
which is available separately, provides guidance to help manage the risks … also introduced new opportunities for
error and other unanticipated outcomes that can present safety risks
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pcmh.ahrq.gov/sites/default/files/wysiwyg/evidencenow/heart-health/aspirin-asa-measure.pptx
April 01, 2016 - Point of Care Tools
ASCVD Risk Calculator app
NIH Heart attack assessment tool
Point of Care Tools (2 … Patient is at a high risk for bleeding (i.e. GI hemorrhage, bleeding disorders documented). … Benefits usually outweigh the risks for secondary prevention. … The ASCVD Risk Estimator provides easy access to recommendations specific to the risk estimates produced … the most current evidence on bleeding and aspirin use to derive a patient’s likely benefits and risks
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module3/mod03-gap-analysis-guide.pdf
April 01, 2016 - Are governance/senior leaders regularly and thoroughly briefed on risks and hazards?
b. … Are patient safety risks, hazards, and opportunities discussed and documented at board meetings?
f. … Comments
Leadership and Culture
Are governance/senior leaders regularly and
thoroughly briefed on risks … Are patient safety risks, hazards, and opportunities
discussed and documented at board meetings? … There is strong consensus that
improved communication between providers and patients about risks to
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pcmh.ahrq.gov/teamstepps/lep/handouts/lepprebehsurvey.html
December 01, 2012 - the care team before seeing the patient where the team leader describes team roles, goals, plans, and risks
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pcmh.ahrq.gov/teamstepps/lep/handouts/leppostbehsurvey.html
December 01, 2012 - the care team before seeing the patient where the team leader describes team roles, goals, plans, and risks
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/safemed_facguide.docx
May 01, 2017 - To reduce the risk of errors, these medications require special safeguards such as the following:
Improving … The key safety elements are the following:
Discussing risks and benefits of oxytocin use for labor induction … Using the maintenance infusion to administer a bolus manually is a high-risk practice that should be … Using transition communication techniques to ensure a shared mental model of plan of care and perceived risks … The key safety elements are the following:
Having unit-established processes for conveying risks and
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/lepprebehsurvey.pdf
October 03, 2012 - care team before
seeing the patient where the team leader describes team roles, goals, plans, and risks
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module4/ebleadership.pdf
January 01, 2013 - researchers have posited that subpar
leadership negatively influences teamwork and increases patient risks … Flight crew collaboration to manage safety risks. Group Organ Stud1990;15(2):177-91.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/leppostbehsurvey.pdf
October 03, 2012 - care team before
seeing the patient where the team leader describes team roles, goals, plans, and risks
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pcmh.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
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pcmh.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/medication/safe-medication-slides.html
July 01, 2023 - Slide 4: High-Alert Medications 1
High-alert medications are "drugs that bear a heightened risk of … 4,5 , 6,7
Use of a uniform mixed preparation unitwide for all patients to reduce variability and risk … Ensures a shared mental model of plan of care and perceived risks—
Between shifts. … Slide 16: Key Safety Elements: Patient and Family Engagement
Discuss risks and benefits of oxytocin … Slide 27: Key Safety Elements: Patient and Family Engagement
Discuss risks and benefits of intrapartum
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pcmh.ahrq.gov/teamstepps-program/welcome-guides/administrators.html
July 01, 2023 - TeamSTEPPS 3.0 tools and concepts can help you equip teams in your organization to better understand these risks … The expanded functionalities available in electronic health records risk an overdependence on technologies … all these factors contribute to fatigue and burnout that create additional challenges for teams and risks
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pcmh.ahrq.gov/teamstepps-program/welcome-guides/frontline-providers.html
July 01, 2023 - TeamSTEPPS 3.0 tools and concepts can help you to better understand these risks and how to constructively … The expanded functionalities available in electronic health records risk an overdependence on technologies … all these factors contribute to fatigue and burnout that create additional challenges for teams and risks
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pcmh.ahrq.gov/sites/default/files/wysiwyg/evidencenow/heart-health/aspirin-use-pcor.pdf
November 01, 2016 - Evidence Now Fact Sheets - Aspirin Use by High-Risk Individuals … Aspirin Use by High-Risk Individuals
Rationale for Aspirin Use by High-risk … Individuals
Patients with heart disease or who have had a stroke in the past are at high risk
for having … Substantial PCOR evidence shows
that taking an aspirin every day can help these patients lower their risk … Information
provided includes the benefits and risks of aspirin use and what to discuss with a doctor
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/traintrainers/lepslstafftrain.pptx
February 02, 2006 - Safety for Patients With
Limited English Proficiency
Overview/Objectives
Understand the safety risk … Inaccurate medical history
Cultural deference to authority
Quadriplegic teen
$71 million lawsuit
High-Risk … OB/GYN
Surgery
Transitions in care, including intake and discharge
Medication reconciliation
Added Risk … medical history
Latex allergy almost missed before surgery
“Opportunity” Scenario
What are the risks
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pcmh.ahrq.gov/hai/cusp/modules/identify/identify.html
December 01, 2012 - identify recurring negative events in your system and apply CUSP and Sensemaking tools to help reduce the risk … What Will You Do To Reduce the Risk of Recurrence? Slide 25. How Will You Know the Risk Is Reduced? … Discuss the three greatest risks.
Rank these risk factors. … What will you do to reduce the risk of recurrence?
How will you know the risk is reduced? … Sensemaking of patient safety risks and hazards. Hlth Svcs Res 2006;41(Aug 4 Pt 2.):1555-1575.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/traintrainers/lepigstafftrain.pdf
November 19, 2008 - Ask participants: What are the risks in this situation? What was
handled well? … and Conflict Resolution
DO:
Read the scenario.
11
DISCUSSION:
• What are the risks … 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 are.
15
DO: Show “Optional Briefs” video.