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www.ahrq.gov/research/findings/nhqrdr/chartbooks/careaffordability/measures3.html
June 01, 2018 - Inefficient care includes delayed care that is more costly and care with risks that exceed benefits. … Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance Survey, 2014
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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-Riley_59.pdf
April 06, 2008 - Problem Statements describe and quantify identified risks the institution faces. … Dashboard methodologies—creates a transparent sequence to ensure that the organization
is aware of the risks … the commercial aviation industry: concrete Problem
Statements that describe and quantify identified risks … Organizing patient safety
research to identify risks and hazards. … Managing the risks of organizational
accidents.
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www.ahrq.gov/talkingquality/assess/recommended-reading.html
May 01, 2019 - Aims, benefits and risks of consumer information initiatives.
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www.ahrq.gov/hai/cusp/modules/identify/identify.html
December 01, 2012 - What Will You Do To Reduce the Risk of Recurrence?
Slide 25. … How Will You Know the Risk Is Reduced?
Slide 26. … Discuss the three greatest risks.
Rank these risk factors. … What will you do to reduce the risk of recurrence?
How will you know the risk is reduced? … Sensemaking of patient safety risks and hazards. Hlth Svcs Res 2006;41(Aug 4 Pt 2.):1555-1575.
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www.ahrq.gov/policymakers/chipra/statesummaries/co-spotlight.html
July 01, 2015 - Colorado supported the implementation of an electronic risk assessment tool
To get a fuller picture … of the health risks facing adolescents, demonstration staff in Colorado and New Mexico—
Developed … an electronic questionnaire that screens adolescents for social and behavioral risk factors, including … ’ tablets so they can discuss health risks with adolescents during their visit. … SBHCs also reported that aggregating the screening data helped them identify the risk factors common
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www.ahrq.gov/hai/cauti-tools/archived-webinars/infectious-complications-slides.html
December 01, 2017 - Slide 6
Risk
Patient with indwelling catheter and colonized urine:
Healthcare worker exposes … Shared instruments (fomites) expose other patients
Unnecessary antibiotics and their side effects, risks … Top arrow points up and says Increased Risk. Bottom arrow points down and says Reduced Risk. … –Unit medical director
Slide 40
Nurse Barriers
Workflow issues
Risk of Foley v. other risks … That's another issue with incontinence in this environment, you know, the benefits versus the risks of
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/safemed_facguide.pdf
May 01, 2017 - To
reduce the risk of errors, these medications
require special safeguards such as the
following: … The key safety elements are the following:
• Discussing risks and benefits of
oxytocin use for labor … Using the maintenance
infusion to administer a bolus
manually is a high-risk practice that
should … transition communication
techniques to ensure a shared
mental model of plan of care and
perceived risks … The key safety elements are the following:
• Having unit-established processes
for conveying risks
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/intro.html
November 01, 2014 - In general, reports help identify residents with increasing risk of pressure ulcer formation and help … Two reports were added to help provide more information about treatment history and changing risks to … Reports: High Risk and Medium Risk
2
Weight Summary Report
3
Trigger Summary Reports … : Resident Level and Unit Level
4
Risk Change Report
5
Intervention History for Nutrition … Risk Reports: High Risk and Medium Risk
6
Resident Clinical, Functional, and Intervention Profile
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/safemedication.pptx
May 01, 2017 - Admin.
3
High-Alert Medications1
High-alert medications are “drugs that bear a heightened risk of … These medications require special safeguards to reduce the risk of errors, such as the following:
Improving … Ensures a shared mental model of plan of care and perceived risks—
between shifts
between units
between … Admin.
15
Key Safety Elements: Patient and Family Engagement
Discuss risks and benefits of oxytocin … Admin.
26
Key Safety Elements: Patient and Family Engagement
Discuss risks and benefits of intrapartum
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www.ahrq.gov/news/blog/ahrqviews/2024-academyhealth-meeting.html
July 01, 2024 - global phenomenon, including draining health system resources, causing workforce burnout, and creating risks
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/assemble/assemble-team-facilitator-guide.pdf
May 01, 2017 - The senior executive should—
• Work with team members to consider
patient risks identified in the Staff … • Involve frontline providers to help
reduce risks,
• Help prioritize risks and develop an
improvement … risks at the L&D unit level. … Further,
when prioritizing risks and developing an
improvement plan with the team, senior
executives … Key hospital departments, such as risk
management, quality improvement, and
infection prevention, that
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/tool_safe-e-fetal-monitoring.docx
May 01, 2017 - 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 … · Include a discussion of risks and benefits of using continuous EFM versus intermittent auscultation … timely, clear information to patient and family to explain what is happening, what needs to happen next, risks
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/science-of-safety-facguide.docx
January 01, 2017 - must develop or improve the ability to learn from mistakes and implement procedures that reduce the risk … as checklists, and create independent checks for key processes, we improve our ability to reduce the risks … By leveraging staff member knowledge, the Staff Safety Assessment allows teams to determine risks that
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www.ahrq.gov/patient-safety/index.html
January 01, 2024 - by Setting
AHRQ has developed a wealth of materials focused on a wide range of patient safety risks
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/handout.html
November 01, 2017 - factors are important for falls so that they are more sensitive to changes in these risks and to helping … us identify residents whose risks are changing and to alert Nurse Managers earlier. … Focusing our team discussions on those residents with new and changing risks seems like it would allow … The Falls High-Risk Report is definitely helping us identify residents with risks associated with falls … The purpose of using the reports is to identify persons with risks associated with unsafe behaviors,
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www.ahrq.gov/news/newsroom/case-studies/201523.html
August 01, 2015 - Effective Health Care Program (EHC) publications, which summarize the benefits and risks of treatment
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www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/covid19-vaccine-confidence-curriculum-learning-guide-staff.pdf
March 01, 2021 - Huddle Wrap-Up
ASK:
What are your thoughts about the risk of COVID-19 vaccination versus the risk … receive the COVID-19 vaccine, like healthcare workers, may choose to be vaccinated.6
• The actual risks … (Talk with your doctor to discuss your risks for getting COVID-19.) … • Due to the severe health risks associated with COVID-19 and the fact that re-infection with COVID-19 … The risks of complications if you contract COVID-19 during pregnancy are
concerning.
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www.ahrq.gov/hai/tools/surgery/modules/sustainability/spreading-slides.html
December 01, 2017 - Recognize risks to sustaining progress:
Staff turnover.
Overlying priorities.
-
www.ahrq.gov/sites/default/files/2024-01/crystal-report.pdf
January 01, 2024 - nursing homes to manage behavioral and
psychological symptoms of dementia, despite increased mortality risk … However, for frail elderly residents, these medications bring
substantial risk. … 2008, the Food and Drug Administration (FDA) imposed a black box warning of
increased mortality risk … The FDA has estimated that such treatment is associated with a 1.6-1.7 times greater risk of death … for frail elderly—for example, increasing the risks of falls that can be
catastrophic.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/or_briefing_audit.docx
December 01, 2017 - Frontline providers understand patient safety risks in their clinical areas and have great insight into … consent
Antibiotics given
Antibiotics redosing time
Beta blockers
Airway risk