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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
May 01, 2017 - objective of this form is to access the knowledge at the frontlines of patient care to determine what risks … List all defects that have the potential to cause harm on your L&D unit,
Discuss the three greatest risks … , and
Rank these risk factors. … How will you know the risk is reduced?
Question 1. … Do staff members believe risks were reduced?
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www.ahrq.gov/news/newsroom/case-studies/201809.html
January 01, 2019 - Shah combed through the toolkit and seized on the device risk checklist as a tool that could provide … Shah saw an opportunity to customize the AHRQ toolkit’s device risk checklist to account for a number … This allows Shah not only to determine whether certain types of patients are at a higher risk for CAUTI … By identifying specific personnel, along with any mistakes that increase the risk of CAUTI, Shah can … Potential pre-contamination risks: Everything from prior incontinence, antibiotic use, and basic hand
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/ambulatory/6bb-toolkit-fasttrack.pdf
January 12, 2021 - Any patient using LtOT, regardless of dose, has a risk of adverse events, including overdose;
2. … Identifying patients using LtOT provides an opportunity to identify those at highest risk so that
they … dashboard of key measures is developed for all patients on LtOT.
☐ Data are used to monitor care gaps, high-risk … www.improvingopioidcare.org:
− Calculation of morphine equivalent dosing;
− Patient function (e.g., PEG);
− Risk … Patient education materials
that include explanation of the
risks and limited benefits of
long-term
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-sops-hospital-survey-workplace-item-set-webcast-wilson-gerdt.pdf
January 01, 2022 - AHA’s Laura
Castellanos on the
HAV Framework
Mitigate
Risk
Access potential risks
and work together … to reduce risks
and improve the
environment
IAHSS – Indiana
Chapter’s Tony
Pope on hospital
security
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/overview-cuspmvp-slides.pptx
January 01, 2017 - Assessment (SSA)
Administer the SSA
Conduct a premortem exercise with your team to proactively identify risks … How will you reduce the risk of it happening again?
How will you know that risk is reduced? … Safety Assessment
Taps wisdom of frontline providers
Helps providers understand the patient safety risks
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/fallspximpl-handouts.pdf
June 02, 2025 - 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. … Facilitator: Sally [Nurse Manager B], do you use a standardized assessment tool to assess resident risks … 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
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/perioperative_asst.docx
December 01, 2017 - Frontline providers understand patient safety risks in their clinical areas and have great insight into … Perioperative Staff Safety Assessment
NAME (OPTIONAL)
JOB TITLE
DATE
CLINICAL AREA
ASSESS RISK … ASSESS RISK FOR SURGICAL SITE INFECTION
Please describe how you think the next patient in the operating
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/handouts2.html
December 01, 2017 - Weekly Risk Meetings (e.g., Pressure Ulcer Risk, Nutrition Risk)
X
9. … strictly for prevention, some of the prevention reports can provide helpful information about residents' risks … The reports help to identify persons with risks associated with pressure ulcers, review care plans, and … Reports provide information about current and changing risks for pressure ulcers and can aid root cause … strictly for prevention, some of the prevention reports can provide helpful information about residents' risks
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/app-m.html
May 01, 2017 - If risk assessment indicates that alcohol flushing and forced air drying are desirable, follow IFUs … Encourage patients and families to discuss with their physician the benefits, risks, and alternatives
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/changes-slides.pptx
November 01, 2019 - uncomplicated biliary infections 2
Piperacillin/tazobactam started empirically Patient does not have risk … How will you reduce the risk of the adverse event from happening again? … How will you know the risk is reduced? … Antibiotic Decision Making
AHRQ Safety Program for Improving Antibiotic Use – Acute Care
Make Sure Risks … Do staff believe risks were reduced?
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-196-fullreport.pdf
January 01, 2020 - Imaging overuse subjects children to a number of risks (Malviya, Voepel-Lewis, Eldevik, et al.,
2000 … Providers should carefully consider the risks and benefits of neuroimaging before
ordering. … The literature offers many examples of the potential risks associated with overuse of imaging. … Projected cancer risks from computed
tomographic scans performed in the United States in 2007. … Frequently asked questions: What are the risks of anesthesia?
2014.
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/ambulatory/6bb-self-assess-tool.pdf
June 02, 2025 - Training on patient-centered,
empathic communication
emphasizing patient safety,
e.g., risks, dose … Patient education materials
that include explanation of the
risks and limited benefits of
long-term
-
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/probabilistic-thinking2.html
September 01, 2022 - For example, the outcome of medical decisions is often incorrectly phrased in terms of “risks” and “benefits
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/018-revision-summary-contact-precautions.docx
October 01, 2024 - Contact precautions, a type of transmission-based precaution, are used to reduce the risk of person-based … A third proposed approach is a “risk-based” strategy for use of contact precautions, where gowns and … personnel is greatest, potentially optimizing the benefits and minimizing potential risks and resource … assessment to determine the potential benefits and risks associated with contact precautions within … Methicillin-resistant Staphylococcus aureus infection and hospitalization in high-risk patients in the
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0198-fullreport.pdf
November 01, 2019 - Imaging overuse subjects children to a number of risks (Malviya, Voepel-
2
Lewis, Eldevik, et al … Burdens of Overuse of Imaging
The literature offers many examples of the potential risks associated … The most severe risks, though rare, include brain damage and death (SPA, 2014). … Projected cancer risks from computed
tomographic scans performed in the United States in 2007. … Frequently asked questions: What are the risks of
anesthesia? Richmond, VA: SPA; 2014.
-
www.ahrq.gov/talkingquality/translate/scores/adjustment-scoring.html
January 01, 2023 - of the patient population, specifically whether—as a group—patients in one facility are at greater risk … Risk adjustment is a complex statistical enterprise. … [1] [2]
Why adjust for risks or severity? … Most common risk adjustments—for age, prior medical history, or comorbidities—are considered a good idea … Risk Adjustment for pediatric quality indicators. Pediatrics 2004 Jan;113(1 Pt 2):210-6.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects_facnotes.docx
December 01, 2017 - The risk must be eliminated for all patients. … Slide 12
How Will You Reduce Risk of Recurrence? … Slide 18
How Will You Know Risks Were Reduced? … Does the staff believe the risks were reduced? … Post the stories in which risks were reduced. Include data to show trends.
-
www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-fac-notes.html
December 01, 2017 - The risk must be eliminated for all patients. … Slide 19: How Will You Know Risks Were Reduced? … Ask:
How are we going to know the risks are reduced? … Does the staff believe the risks were reduced? … Post the stories in which risks were reduced. Include data to show trends.
-
www.ahrq.gov/sops/about/patient-safety-culture.html
June 01, 2024 - Higher Centers for Medicare & Medicaid Services (CMS) Nursing Home Five-Star Quality ratings. 5 Lower risks
-
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-patient-safety-slides.pptx
June 01, 2021 - Safety
2
Revolutionized modern medicine
Saved countless lives
However, antibiotics have risks … Patient Safety
6
Increased risk of getting Clostridioides difficile infection (CDI) occurs5,6
While … Social influences include
Fears, risks, fatigue
Other prescribers outside of long-term care facilities … How can you reduce the risk for next time?
How will know that your changes worked? … Meta-analysis of antibiotics and the risk of community-associated Clostridium difficile infection.