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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/108-performing-premortem-project-assessment.pptx
April 01, 2025 - Gain prospective hindsight5
Reduce overconfidence
Involve cross-functional teams
Align team on project risks … the Process
To keep your program going strong, meet again and continue to “look forward” and mitigate risks
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www.ahrq.gov/research/findings/studies/index.html?page=422
January 01, 2024 - focus on the patient and care coordination. e-Rx adoption increased workload and introduced safety risks … of hospital admissions: do risks differ for men and women? … Ambient PM2.5 and risk of hospital admissions: do risks differ for men and women? … R Changes in classes of injury-related risks and consequences of risk-level drinking: a latent transition … Changes in classes of injury-related risks and consequences of risk-level drinking: a latent transition
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/109-performing-premortem-project-assessment-fg.docx
April 01, 2025 - wants the project to succeed so badly that unconscious bias will lead the group to underestimate the risks … improving environmental cleaning, invite members of the environmental cleaning team.
· Align on project risks … the Premortem Project Assessment is the opportunity to make plans and take actions to mitigate the risks
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www.ahrq.gov/news/blog/ahrqviews/heart-month-tools.html
February 01, 2023 - morbidity and mortality by about 20 percent; it also reduces hospital admissions by 28 percent and the risk … Diagnosing and treating heart disease in its early stages is crucial to reducing patients’ risks of serious … collection of resources to help primary care practices implement the best evidence for reducing cardiac risks … It includes Integrating Cardiovascular Disease Risk Calculators into Primary Care , a guide to help … primary care physicians assess their patients’ risk of a cardiovascular disease event.
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www.ahrq.gov/patient-safety/reports/healthaffairs.html
March 01, 2019 - with patient safety research experts in bringing innovative approaches to significantly reduce the risks
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www.ahrq.gov/sites/default/files/wysiwyg/coronavirus/long-covid-care-network/sparc-grantee-profile.pdf
January 01, 2024 - PACT is implementing targeted approaches for older adults and
individuals with complex needs or social risks … To
address social risks, JH PACT is adopting a standardized screening
process for social determinants
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/training-for-healthcare-professionals.pdf
January 01, 2014 - Department of Veterans Affairs
Barbara Giardino, RN, BSN, MJ, CPHRM, CPPS
Risk Manager, Rockford … small risk of central-line associated bloodstream
infection (CLABSI) versus not completing the course … of antibiotics (no
CLABSI, but risk of meningitis recurring)]. … Tabor answered questions about relative risks of each
option. … www.hhs.gov/ohrp/education/index.html
AHRQ Informed Consent and Authorization Toolkit for Minimal Risk
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www.ahrq.gov/sites/default/files/wysiwyg/health-literacy/professional-training/training-for-health-care-professionals.pdf
January 01, 2014 - Department of Veterans Affairs
Barbara Giardino, RN, BSN, MJ, CPHRM, CPPS
Risk Manager, Rockford … small risk of central-line associated bloodstream
infection (CLABSI) versus not completing the course … of antibiotics (no
CLABSI, but risk of meningitis recurring)]. … Tabor answered questions about relative risks of each
option. … www.hhs.gov/ohrp/education/index.html
AHRQ Informed Consent and Authorization Toolkit for Minimal Risk
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www.ahrq.gov/news/cahps-research-meeting.html
September 01, 2023 - experience
How better communication with patients can improve patient safety and lower malpractice risks
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmodap3b.html
October 01, 2014 - Risk assessments of residents for falls include all of the following except:
Strength. … The team has to watch out for any environmental risks.
Everything has to be documented. … An individual's condition and treatment can directly impact his/her fall risk. … The team has to watch out for any environmental risks.
Everything has to be documented. … An individual's condition and treatment can directly impact his/her fall risk.
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www.ahrq.gov/hai/cusp/modules/engage/exec-notes.html
December 01, 2012 - They should also join frontline providers and managers for rounds and a monthly meeting to discuss risk … Involve frontline providers to help reduce risks. … By addressing patient risks identified in the Staff Safety Assessment, senior executives are partnering … with their teammates to tackle risks at the unit or hospital level. … Further, when prioritizing risks and developing an improvement plan with the team, senior executives
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/sustainability/premortem-scorecard-slides.pptx
January 01, 2017 - sustainment and spread
Plan key actions for sustainment
Prioritize needs for successful sustainment
Identify risks … Avoid recidivism, or backsliding
Respect probability of failure over time
Recognize risks to sustaining … Target the potential risks for failure to achieve sustainment goals
Remember that sustainability is a … per quarter
Consider participating in morbidity and mortality conferences
Post the stories of reduced risks
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/tool-safe-csection.html
July 01, 2023 - Preoperative briefing
The briefing reviews the plan ahead for patient care and the risks or concerns … It includes reviewing patient information, procedure, indications, risk, medical history, fetal status … Probabilistic risk assessment.
Causal tree worksheet. … of transition communication techniques assures a shared mental model of plan of care and perceived risks … Patient and Family Engagement (CUSP Module)
Communicate risks and benefits of cesarean delivery
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/audio-script-leaders-training.pdf
January 18, 2017 - This course is for quality improvement and patient safety leaders, risk management leaders, and
unit … Informed Consent Policy Improvement Task Force should include:
• Legal
• Risk management
• Medical … , including remote but severe risks. … Verbal consent is required for routine treatments and procedures with very low risk, but not
minimal … risk, such as the administration of most drugs, blood draws, and minor procedures, such
as routine
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cusp-icu-notes.docx
April 01, 2022 - A strong culture of safety can bolster staff resiliency and lower the risks of burnout. … Keep in mind that process defects may be identified that did not cause harm but put patients at risk … · How will you reduce the risk of the defect happening again? … · How will you know the risk is reduced? … second-order problem solving focused on learning the origins of a defect and devising solutions to lessen the risk
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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/funding/process/grant-app-basics/hsubjects.html
August 01, 2018 - involvement of human subjects and proposed protections according to the following review criteria:
Risk … Adequacy of protection against risks. … various reasons, some related to the claims about the research protocol (e.g., for exemption or the risk … inadequate procedures to maximize privacy and confidentiality or subjects not adequately informed about risks
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/154-performing-pre-mortem-project-assessment.pptx
October 01, 2024 - Gain prospective hindsight5
Reduce overconfidence
Involve cross-functional teams
Align team on project risks … the Process
To keep your program going strong, meet again and continue to “look forward” and mitigate risks
-
www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/medication/tool-safe-oxytocin.html
July 01, 2023 - In obstetrical emergencies where benefit-to-risk ratio favors surgical intervention. … of error. 12
The risks and benefits of low- versus. high-dose oxytocin protocols remain an active … Probabilistic risk assessment.
Causal tree worksheet. … Use unit-established process for conveying risks and benefits of oxytocin use to patient and family. … and documentation of the discussion about risks, benefits, and alternatives should be documented to
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/facslides.html
September 01, 2017 - May focus on a particular risk factor. … Report—High Risk. … 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 care plan changes.