-
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions5.html
June 01, 2023 - found that diagnostic error may have contributed to 10.6 percent of 7-day readmissions in this high-risk
-
www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/about/impact-stories/increasing-access.pdf
January 01, 2023 - current standard of
care for treatment of opioid use disorder (OUD) to reduce
opioid use, reduce risk
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/ipe-large-org-webcast-skootsky.pdf
March 01, 2021 - Training for Care Coordinators ( PSR) – these staff are
responsible for the coordination of care for high risk
-
www.ahrq.gov/healthsystemsresearch/hspc-research-study/appendix-d.html
June 01, 2020 - Delivery leaders and other stakeholders can then use these results in combination with their own risk
-
www.ahrq.gov/nursing-home/resources/search.html
January 01, 2022 - Implications for Reopening This study provides important preliminary results on the level of population risk
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-transcript-508-compliant.pdf
June 01, 2017 - first coined, or one of the first people that coined
it, was James Reason in his book, Managing the Risks … make
a similar list, but this is who we sent: myself, the Patient Safety Officer; the Director for Risk … has to identify the human behavior type that they're counseling the
employee about, human error, at risk … reported to the
Board of Nursing that they would also look, what kind -- was this human error, at risk
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmod2.html
October 01, 2014 - Content Overview
Clinical Content
A change in a resident's condition may mean that he or she is at risk … Why communication lapses are a major risk factor for resident safety. … Actors should not be afraid to take risks.
Feel free to be spontaneous.
-
www.ahrq.gov/sites/default/files/2024-01/daugherty-report.pdf
January 01, 2024 - including poor collaborative communication among nurses and
physicians, contributed to increased patient risk-adjusted … Table 1: Contributing factors in patient occurrence reports, 2004-2005
Contributing Factors
2004 Risk … Manager
score Percent
2005 Risk
Manager
Score Percent
1. … 100%
Contributing factors in patient occurrence reports: team factors, 2004-2005
Team Factors
2004
Risk … Manager
Score
Percent
2005
Risk
Manager
Score
Percent
Communication problems between providers
-
www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/implementation-guides/implementation-guide1/impguide1step1.html
March 01, 2019 - What are the political risks of embarking on a stakeholder engagement process? … Conversely, are there any political risks associated with not having a stakeholder engagement process
-
www.ahrq.gov/teamstepps-program/curriculum/situation/tools/step.html
June 01, 2023 - changes are of particular importance and whom to contact if a change occurs is key to ensuring that risks
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/leveraging-cultural-change-080814.pptx
January 01, 2013 - four areas of beliefs and behaviors that interact to produce an organization that is informed about risks … The foundation of every culture of safety is
Reporting -- the people in direct contact with risks and
-
www.ahrq.gov/ncepcr/reports/cost-guide/collection-tools.html
February 01, 2017 - Risks or discomforts: No risks or discomforts are anticipated.
-
www.ahrq.gov/ncepcr/research-transform-primary-care/transform/cost/app-b.html
October 01, 2015 - Risks or discomforts: No risks or discomforts are anticipated.
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-hit-hie.pdf
June 01, 2023 - Chemotherapy
Processes
2003-
2005
$200,000 Purpose: Evaluate the risks associated with each step … Florida
Robert Wears
University of Florida
Gainesville, Florida
R18 HS17902
[Grant]
Reducing Risks … Graphics
2006-
2009
$100,000 Purpose: Develop novel interactive computer graphics
to communicate risks … and assess their impact on
decision making and risk perception. … benefit from
prospective medication monitoring care plans when
complex medication regimens carry risks
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety_facguide.docx
May 01, 2017 - Checklists help to facilitate safety in high-complexity, high-risk, and high-reliability professions … sections
Slide 9
SAY:
The preoperative briefing reviews the plan ahead for patient care and the risks … .18-21
· Individual risk factors predict some occurrences of obstetric hemorrhage.
· Risk assessments … These include—
Having situational awareness about maternal and fetal risks and status. … during transitions of care helps to assure a shared mental model of the plan of care and perceived risks
-
www.ahrq.gov/talkingquality/translate/scores/framing.html
March 01, 2016 - A negative frame would emphasize the risks of choosing a relatively poor performer.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/patient-family-engagement-ed.pptx
September 01, 2014 - Concerns/fears: Risks of an infection, esp. as it relates to UC
Skills/Knowledge (e.g. communication
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/conflict_resolution-slides/Conflict-Resolution-Oct-12-2010-508.ppt
January 01, 2010 - with Clinicians
L--Can you help me understand how you see the situation, how you are weighing the risks
-
www.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program-apa.html
April 01, 2018 - Research to Implementation'
'AHRQ' Patient Safety Initiative: Building Foundations, Reducing Risk … Patient Safety Assessment Tool (PSAT)'
'Patient Safety Culture Surveys/Tools’
'Probabilistic Risk … Evidence-based Practice
Health Care Team Coordination
Identification and Mitigation of Risks … Plan-Do-Check-Act (PDCA)
Practice-Based Learning and Improvement
Quality Management
Risk
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Lavelle_33.pdf
March 12, 2008 - There was no risk to patients. … /oxygenation safety risks
Intubation supplies on code cart; but few ACSL-
trained staff; intubation … to quickly clear
mouths; add second heavy-duty extension cord
to code cart
Medication safety risks … plan
Medication safety risks (continued)
Staff drew up meds through metal bottoms
of cartridges … ECG machine if 12-lead ECG is
needed or actual rhythm needs to be observed
System and process risks