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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.
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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
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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
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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.
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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
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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,
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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?
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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
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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
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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
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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
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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
risks … risks. … 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
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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
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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
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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
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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
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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 risk • Risk is still elevated up to 12 weeks later 11
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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
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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].
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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,