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teamstepps.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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teamstepps.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module1/mod1-slides.html
March 01, 2017 - Slide 18: Understanding Risk and Human Behavior 1
Human Error:
Inadvertently completing the wrong … At-Risk Behavior:
Choosing to behave in a way that increases risk where risk is not recognized, or … Reckless Behavior:
Choosing to consciously disregard a substantial and unjustifiable risk.
1. … Slide 19: Managing Error and Risk 1
Human Error
At-Risk Behavior
Reckless Behavior … believed insignificant or justified
Manage through:
Removal of incentives for at-risk behaviors
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teamstepps.ahrq.gov/evidencenow/projects/heart-health/about/cooperatives/nyc.html
March 01, 2021 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … need to help their patients adopt the ABCS of cardiovascular disease prevention: A spirin in high-risk … Heart disease is the primary cause of death in the city, and prevalence of cardiovascular disease (CVD) risk … support ABCS-driven care
Three expert webinars on topics related to evidence-based management of CVD risk … care practices [AcademyHealth, 2017]
Using Practice Facilitation in primary care settings to reduce risk
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teamstepps.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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teamstepps.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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teamstepps.ahrq.gov/challenges/cds-connect/index.html
February 01, 2024 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … Agrees to assume any and all risks and waive claims against the Federal Government and its related entities
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teamstepps.ahrq.gov/news/newsroom/case-studies/201801.html
April 01, 2018 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … 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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teamstepps.ahrq.gov/opioids/health-systems-research.html
July 01, 2021 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … 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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teamstepps.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/liquid-biopsy-topicrefinement.pdf
July 29, 2021 - the importance of the false
positive rate may vary greatly for each cancer type, depending on the risks … Comment: It is not necessary to include "high risk" in the diagnosis paradigm. … Genetic/Familial High-Risk Assessment:
Colorectal.(Version 3. 2019). … liquid biopsy or otherwise,
necessarily and appropriately differ for different cancers because the risks … and benefits of
subsequent treatments and interventions differ, and therefore so too do the risks and
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teamstepps.ahrq.gov/patient-safety/settings/hospital/candor/impguide.html
August 01, 2022 - patient satisfaction and patient experience of care surveys have been shown to predict malpractice risk … . 4 Eliminating or reducing the risks and hazards in the delivery of patient care should yield safer … MODULE 2: Obtaining Organizational Buy-In and Support
Obtaining senior leadership and risk management … This team is responsible for working with legal counsel, claims, and risk management staff to establish … The use of patient satisfaction surveys and alternative coding procedures to predict malpractice risk
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teamstepps.ahrq.gov/talkingquality/measures/understand/patient-comments.html
February 01, 2016 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … 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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teamstepps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module4/module4_pu-implementation_slides.pptx
November 20, 2014 - Conducting pressure injury risk
assessments.
Planning care for risk prevention. … Unit staff tell the Wound Care Team about high-risk patients or if skin problems occur. … Page 65
23
Electronic Health Record Opportunities
What information about pressure injury risk factors … logical place in the record to collect, organize, and assess information about patient pressure injury risk … plan/documentation
Staff Education: RN, CEO, CNO, PCT
2-hour didactic competency training:
Braden risk
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teamstepps.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/webinar03/logicmodelsl.html
July 01, 2013 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … The Full Services Partnership addresses needs and risks.
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teamstepps.ahrq.gov/news/newsletters/e-newsletter/876.html
August 01, 2023 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … monitoring, also based on the systematic review, found postpartum home monitoring significantly reduced the risk … Implementation of suicide risk estimation analytics to support mental health care for quality improvement … Factors associated with lung cancer risk factor documentation. … Adapting an electronic STI risk assessment program for use in pediatric primary care.
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teamstepps.ahrq.gov/sites/default/files/wysiwyg/evidencenow/cooperatives/evidencenow-executive-summary-nc.pdf
November 01, 2017 - they need to help their patients adopt the
ABCS of cardiovascular disease prevention: Aspirin in high-risk … and
almost one-third of deaths are caused by CVD (the CVD mortality rate is 251 per
100,000).2 CVD risk … Over 90 percent of practices have access to CVD
risk stratification tools. … ASCVD Risk Estimator Update 2014. … http://tools.acc.org/ASCVD-Risk-Estimator/#page_about
6 http://www.implementationscience.com/content
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teamstepps.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3.html
August 01, 2022 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … Others as appropriate
Board Members
Members of the hospital or system board
Quality, Safety, and Risk … Management
Selected leaders from these areas:
Quality
Safety
Risk management
Patient relations … types
Vice-Presidents
Emergency department
Operating room
Surgery
Obstetrics
Other high-risk … Unit-Level Staff
Emergency department
Radiology
Surgery
Obstetrics
Pharmacy
Other high-risk
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teamstepps.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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teamstepps.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-5/slides.html
September 01, 2017 - Performance of care planning that addresses each risk factor identified during fall risk factor assessment … Ensure that known risk factors for falls are assessed. … Slide 41: Care Planning Assessment
All risk factors identified on the fall risk factor assessment … Tailored approach to each patient, based on the patient’s risk factors. … Ensure that care plans address all areas of risk.
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teamstepps.ahrq.gov/hai/cusp/videos/index.html
September 01, 2019 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … 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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teamstepps.ahrq.gov/patient-safety/resources/learning-lab/building-ambulatory-long-desc.html
April 01, 2021 - needs-driven technical and culture-based solution for subcritical test results, management of high-risk … professionals to actively track subcritical test results (e.g., pulmonary nodules) and monitor high-risk … electronic registry for urology clinic staff to monitor men on active surveillance for prostate cancer risk … jirovecii pneumonia (PJP) prophylaxis patterns among patients with rheumatic diseases receiving high-risk … a novel method to develop context-sensitive interventions to reduce quality gaps in monitoring high-risk