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  1. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Pronovost_95.pdf
    June 12, 2008 - MD, MPH Abstract Use of patient safety reporting systems (PSRS) to identify and mitigate risks … A local patient care area can reduce risks that are unique to it; a hospital can reduce risks that span … Nevertheless, current approaches to mitigating risks are probably neither efficient nor effective. … Who should be responsible for attempting risk mitigation? … The highest level possible should attempt to mitigate the risk.
  2. www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/slides.html
    December 01, 2014 - May focus on a particular risk factor. … Identify residents with recent changes in risks. Profile risks for each resident in report. … Each Self-Assessment worksheet is designed to help nursing home staff review how they: Screen for risks … Mitigate those risks. Prioritize residents who may need changes to care plans. … How the nursing home identifies risk factors for adverse events and communicates changes in risk to clinical
  3. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/factraining_slides.pptx
    December 01, 2014 - Does information exist to identify residents at risk? How can this information be used? … preventing adverse events Proactive rather than reactive Identify residents with recent changes in risks … Profile risks for each resident in report Prioritize residents for possible changes to their treatment … Worksheet Each Self-Assessment worksheet is designed to help nursing home staff review how they: Screen for risks … associated with each of the On-Time program’s adverse events Mitigate those risks Prioritize residents
  4. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/ontime-preventablehospitaledvisits-overview.pptx
    May 01, 2017 - Does information exist to identify residents at risk? How can this information be used? … preventing adverse events Proactive rather than reactive Identify residents with recent changes in risks … Profile risks for each resident in report Prioritize residents for possible changes to their treatment … Worksheet Each Self-Assessment Worksheet is designed to help nursing home staff review how they: Screen for risks … Mitigate those risks. Prioritize residents who may need care plan changes.
  5. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/113-staff-safety-assessment.docx
    October 01, 2024 - & Non-ICU Purpose of this form: This form is designed to tap into your experience to determine what risks
  6. www.ahrq.gov/sites/default/files/wysiwyg/patients-consumers/prevention/lifestyle/women-over-50.pdf
    March 01, 2014 - If you are younger than 65 and at high risk for bone fractures, you should also be screened. … Talk with your health care team about your risk for bone fractures. Overweight and Obesity. … Talk to your doctor about your risks for breast cancer and whether you should take medicines that may … reduce those risks. … If you are 65 or older and have a history of falls, mobility problems, or other risks for falling,
  7. www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/coordination/ccqmpc/ccqm-pc-mail.pdf
    July 01, 2016 - What are the risks and benefits? … There are no anticipated or known risks for you for completing this survey. … What are the risks and benefits? How will you protect my privacy?
  8. Facilitator-Notes (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module2/facilitator-notes.docx
    March 01, 2017 - · Experimenting and taking risks, remaining open to new ideas, encouraging small tests of change to … They should also join frontline providers and managers for rounds and regular meetings to discuss risk … Senior leaders need to hold themselves and staff members accountable for reducing resident risks. … rounds can be used to improve communication across the organization, to capture information about high-risk … Executive WalkRounds™—to improve communication across the organization, capture information about high-risk
  9. www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module2/mod2-facguide.html
    March 01, 2017 - They should also join frontline providers and managers for rounds and regular meetings to discuss risk … The senior leader— Shares information about safety risks identified at the system level. … Discusses resident risks identified in the Staff Safety Assessment with team members. … rounds can be used to improve communication across the organization, to capture information about high-risk … Executive WalkRounds™—to improve communication across the organization, capture information about high-risk
  10. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/066-staff-safety-assessment.docx
    April 01, 2025 - Surgeries Purpose of this form: This form is designed to tap into your experience to determine what risks
  11. www.ahrq.gov/patient-safety/reports/liability/baker.html
    August 01, 2017 - how to include patients and families in the care team and how to communicate with patients about the risks … families to be effective team members, and how to communicate with patients and families about the risks … degree of inter-rater agreement across respondents to see if our clinical experts agreed regarding the relative … Triage / Assessment Clinician does not sufficiently educate patient/family about risks. … Intra-Partum Fetal Death Pre-Hospital Clinician does not educate mother/family about risks
  12. www.ahrq.gov/sites/default/files/2024-02/yazdany-report.pdf
    January 01, 2024 - Results: The project generated new epidemiological evidence of patient safety risks and adverse events … We also sought to use epidemiological data to develop and implement “eMeasures” to monitor these risksrisks. … the increased number of medications available and fractured care across multiple providers, safety risks … At least 25% of patients with the highest-risk conditions (e.g., vasculitis) or highest-risk immunosuppressants
  13. www.ahrq.gov/sites/default/files/wysiwyg/stepup_Challenge/step-up-challenge-phase-1-webinar-slides.pdf
    September 24, 2018 - time saved, increases in patient-reported outcome data exchanges between patients and providers) Risks … & Mitigation Strategies • Show potential risks and mitigation strategies, including security constraints … The proposed solution clearly defines potential risks and mitigation strategies including security constraints … usingtheapplication,time saved,increases inpatient-reported outcomedata exchanges betweenpatients andproviders) Risks … Theproposed solution clearlydefinespotential risks and mitigation strategies including security constraints
  14. www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide166.html
    October 01, 2014 - to have a medical/health care clinician deliver a strong message to quit, information about health risks
  15. www.ahrq.gov/cpi/about/organization/nac/emert.html
    February 01, 2025 - conduct research and identify healthcare disparities, chronic disease trends, and infectious disease risks
  16. www.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
  17. www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/antibiotic-prescribing-guide.docx
    September 01, 2022 - However, all antibiotics, whether necessary or not, are associated with risks. … aortic dissections, seizures, and peripheral neuropathy—highlighting the importance of weighing the risks … The risk is highest when patients are actively receiving antibiotics, but this risk remains elevated … However, inappropriate antibiotic prescribing is a safety problem, and it exposes patients to unnecessary risks … : 7X risk – Fluoroquinolones: 5X riskRisk is still elevated up to 12 weeks later 11
  18. www.ahrq.gov/funding/grantee-profiles/grtprofile-malone.html
    September 01, 2023 - commonly overridden DDI warnings and identified specific patient and drug attributes that influence the risk … Malone received a 2-year AHRQ grant to adapt and implement a CDS algorithm to reduce at-risk patients … disseminate decision aids that enable patients and clinicians to engage in shared decision making about DDI risks … harm due to DDIs, there are very few tools that help them engage in shared decision making about DDI risks
  19. www.ahrq.gov/sites/default/files/2025-04/marin-report.pdf
    January 01, 2025 - As with all testing or interventions performed, there are risks to unnecessary imaging tests. … a result.29-32 Intravenous contrast may be associated with acute kidney injury and an albeit low risk … Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: … Cancer risk in 680 000 people exposed to computed tomography scans in childhood or adolescence … Doctors May Risk Overuse of CT Scans [Internet].
  20. www.ahrq.gov/sites/default/files/wysiwyg/patients-consumers/prevention/lifestyle/healthy-women.pdf
    May 01, 2014 - If you are younger than 65 and at high risk for bone fractures, you should also be screened. … Talk with your health care team about your risk for bone fractures. … Talk to your doctor about your risks for breast cancer and whether you should take medicines that may … reduce those risks. … If you are 65 or older and have a history of falls, mobility problems, or other risks for falling,

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