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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-slides.pptx
January 01, 2017 - First-Order
Problem Solving
Second-Order
Problem Solving
Recovers for one patient, but does not reduce risks … for future patients
Example: You get the supply from another area or you manage without it
Reduces risks … How will you reduce the risk of it happening again? … How Will You Reduce Risk Reoccurring? … Do staff believe risks were reduced?
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www.ahrq.gov/research/findings/final-reports/stpra/stpra4.html
April 01, 2018 - Study Strengths and Limitations
ST-PRA is a valuable and important tool for assessing the risks associated … unique combinations of risks that contribute to the adverse outcome. … Return to Contents
Next Steps
The use of ST-PRA as a modeling tool to identify risks in the ASC … years, there have been a variety of methods and tools designed to improve our understanding of the many risks … and easier to use by health care providers as they attempt to improve system design and reduce the risks
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www.ahrq.gov/news/newsletters/e-newsletter/680.html
September 01, 2019 - Readmission Among Dialysis Patients Carries Greater Risks, AHRQ Study Finds
Issue Number … Calendar Year, 2013-2016. )
Today's Headlines:
Readmission Among Dialysis Patients Carries Greater Risks … Readmission Among Dialysis Patients Carries Greater Risks, AHRQ Study Finds
Patients receiving dialysis … who were hospitalized multiple times had a higher risk of poor outcomes than those who were not hospitalized … Such patients were at substantially higher risk of subsequent hospitalization and death and a lower likelihood
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www.ahrq.gov/hai/cusp/toolkit/content-calls/framework-slides/slides.html
October 01, 2014 - Ensure unit team has resources to reduce risks. … What could you do to reduce risk?
How do you know risk was reduced? … Do staff believe risks have been reduced?
Return to Contents
Slide 31. … What are potential risks during the day; how can we reduce these risks? … Safety survey to identify at-risk departments.
Mandatory science of safety training.
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-overview/slide32.html
October 01, 2014 - Recommendation: Because of the serious risks of smoking to the pregnant smoker and the fetus, whenever
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www.ahrq.gov/sites/default/files/wysiwyg/opioids/compendium/opioids-compendium-self-assessment.pdf
December 01, 2023 - older
adults, such as screening
for opioid-related risks
(falls, etc.) or medication
management. … for opioid
related risks (falls, etc.) … , such as screening
for opioid-related risks
and recommendations
for improved medication
management … A policy and agreed
upon standard of
practice about
screening for risks of
adverse events in older … An opioid treatment
agreement/plan
customized for older
adults that describes
risks specific to older
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/audio-script-healthcare-professionals-training.pdf
January 18, 2017 - For example, many Americans have trouble understanding numerical expressions of
risk. … Interrupting is OK if patient understanding is at risk. … “Every treatment has some risks. … Some goals may be long-term, such as reducing the risk of future injury or
illness, or living as long … When there’s a risk of harm rather than a virtual certainty, it can be challenging to explain.
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www.ahrq.gov/hai/cusp/modules/engage/exec-slides.html
December 01, 2012 - Considers patient risks and involves frontline personnel in creating ways to mitigate those risks. … Slide 13: Collaborates To Develop and Implement a Plan Addressing Safety Issues
Considers patient risks … Involves frontline providers to help reduce risks.
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www.ahrq.gov/research/findings/final-reports/stpra/stpraexh3.html
April 01, 2018 - Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers
Exhibit 3. … criteria for literature review
Previous Page Next Page
Table of Contents
Proactive Risk … Risk-Informed Interventions
Chapter 4. Conclusions and Next Steps
Appendix A. … e.g., academic medical centers)
Specific studies on hospital and care related infections and their risks … or refute information from the site visit estimates
Studies containing risk factor estimates related
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www.ahrq.gov/evidencenow/heart-health/smoking/use.html
August 01, 2018 - Tobacco Use
Resource description: This script and slide deck from a 14-minute presentation cover the risks
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www.ahrq.gov/evidencenow/heart-health/aspirin/stroke.html
September 01, 2018 - description: This patient education booklet explains how heart attack and stroke happen, and the potential risks
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool1b.docx
January 28, 2013 - Interest or requirement in the program
What the program needs from stakeholder
Perceived attitudes and risks … The program may need to add or make changes to any parts of the EHR that concern fall risk assessment … Interest or requirement in the program
What the program needs from stakeholder
Perceived attitudes and risks
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide205.html
October 01, 2014 - Pregnant Smokers
Recommendation: Because of the serious risks of smoking to the pregnant smoker and
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/shareddec-2.pdf
September 01, 2016 - It includes exploring and comparing the benefits
and risks of each option within a clinical decision … went to the health center, I wanted my doctor to
give me an antibiotic, but once I understood the risks
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/shareddecisionmaking/workshop/module1/shareworkshop-mod1guide.pdf
August 01, 2014 - Discuss benefits/risks/costs.
Clarify patient’s values/preferences. … The provider presents
the options, describes the risks and benefits of
each, and explores patient’s … Clearly communicate risks and
benefits of each option. … Let’s discuss your options and go over the benefits and risks at our next visit.” … “When you think about the possible risks, what matters most to you?”
-
www.ahrq.gov/npsd/quality-patient-safety/index.html
August 01, 2020 - sufficient volumes of patient safety data to identify more rapidly the trends and underlying patterns of risks
-
www.ahrq.gov/evidencenow/heart-health/smoking/detailing.html
August 01, 2018 - Primary Care
Resource description: This facts-at-a-glance handout for clinicians summarizes evidence, risks
-
www.ahrq.gov/hai/cauti-tools/impl-guide/implementation-guide-appendix-l.html
October 01, 2015 - Poster on Urinary Catheter Risks and Indications
Appendix F. … RAISE AWARENESS AND UNDERSTAND THE RISKS OF INDWELLING URINARY CATHETERS
Possible misconceptions: … Unnecessary catheterization puts patients at risk for urinary tract infections and may cause other complications … such as multidrug-resistant organisms, additional antibiotics leading to increased risk of Clostridium
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/170-cusp-science-safety-notes.docx
October 01, 2024 - Slide 3
Risks of Healthcare-Associated Infections (HAI)
SAY:
The risk of healthcare-associated infections … The risk is even higher for patients in intensive care units (ICU), where 30 percent develop an HAI. … This reduces the risk that future patients will be harmed by the same type of error. … Given her trauma, he was concerned about Susan’s bleeding risks. … The hospital didn’t have a standardized protocol for VTE risk assessment.
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/169-cusp-science-safety-slides.pptx
October 01, 2024 - Hospitals face pressures, including balancing safety risks with costs. … providing essential safety-related information, but clear lines are drawn between human error and at-risk … Due to psychological safety, there is no risk when people report their errors and near-misses. … The hospital does not have a standard VTE risk assessment protocol. … Framework for analyzing risk and safety in clinical medicine. BMJ. 1998;316(7138):1154-7.