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www.ahrq.gov/sites/default/files/2024-10/kennerly-ballard-report.pdf
January 01, 2024 - Moving from Adverse Events to Underlying Risks
Methods initiated in safety science for the petro-chemical … AE Prioritization Framework
Sources of risks
and hazards Preventable
(High – Low)
Not Preventable … of the root hazards/risks (causes) using
the Eindhoven Classification Matrix – Medical Version. … Age-related risks of long-term oral
anticoagulant therapy. Arch Intern Med. … Sensemaking of patient safety
risks and hazards. Health Serv Res.
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-0232-table2.pdf
January 01, 2011 - Level of
Evidence
(USPSTF
Ranking*)
Citations
Expert
recommendation
Hypertension is a risk … particularly hypertension), and early deaths
resulting from heart disease or stroke, to
assess the risks … Risk factors and risk behaviors accelerate the
development of atherosclerosis, and risk
reduction delays … culminates in thrombosis,
III Expert Panel on Integrated
Guidelines for Cardiovascular
Health and Risk … on Integrated Guidelines for
Cardiovascular Health and
Risk Reduction in Children
and Adolescents:
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www.ahrq.gov/hai/tools/mrsa-prevention/toolkit/cusp.html
October 01, 2024 - Performing a Premortem Assessment The Premortem Tool is a proactive way to anticipate risks and failures
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www.ahrq.gov/hai/tools/mrsa-prevention/toolkit/vap.html
October 01, 2024 - NV-HAP After reviewing the content of this presentation, viewers will be able to: Discuss the causes and risks
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www.ahrq.gov/patient-safety/resources/learning-lab/owll-long-desc.html
August 01, 2025 - settings by establishing a learning health system that used adverse event (AE) data to identify safety risks
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www.ahrq.gov/funding/process/grant-app-basics/apptips.html
February 01, 2025 - project involves clinical research, are the plans for 1) protection of human subjects from research risks … evaluate the justification for involvement of human subjects and the proposed protections from research risk … relating to their participation according to the following five review criteria: 1) risk to subjects … , 2) adequacy of protection against risks, 3) potential benefits to the subjects and others, 4) importance
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www.ahrq.gov/hai/cauti-tools/ena-slides/preface.html
October 01, 2015 - Avoiding unnecessary procedures will eliminate the risk of infection for those patients. … In many cases, it is not just the UTI that is avoided, but also the more serious risk of urosepsis. … Every time we can avoid unnecessary antibiotic use, we reduce risks for our patients.
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0197-fullreport.pdf
November 01, 2019 - Imaging overuse subjects children
2
to a number of risks (Malviya, Voepel-Lewis, Eldevik, et al … The literature offers many examples of the potential risks associated with overuse of imaging. … The most severe risks, though rare, include brain damage and death (Society for Pediatric
Anesthesia … 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.
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-pfe.pdf
January 01, 2023 - self-governance, fostered a fair and just culture of patient safety, and reduced
avoidable lawsuit risks … ■ User-friendly tools and resources to help patients and families better understand clinical risks, … graphics
illustrating the risk. … Key Findings/Impact: Patients perceived medical-
error risks based on dreadedness and preventability, … The potential risks identified are from the patients’
perspective and have highlighted some possible
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
December 01, 2017 - How will you reduce the risk of it happening again?
4. How will you know the risk is reduced? … Slide 42
How Will You Know Risks Were Reduced?
SAY:
Plan how you will measure success. … Slide 43
How Will You Know Risks Were Reduced? … Slide 44
How Will You Know Risks Were Reduced? … Show your staff that you’ve reduced the risks for patient harm.
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-2.html
June 01, 2020 - diagnostic performance should hence consider the broader context of value-based care, including quality, risks … EHRs can be useful for measuring both discrete (and perhaps relatively uncommon) events and risks that … Emerging patterns that may suggest high-risk situations.
Peer review. … Risk management sources.
Malpractice claims.
Autopsy. … Selection of high-risk cohorts (such as patients with cancer or epidural abscess).
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/tool-cord-prolapse.html
July 01, 2023 - Create Independent Checks (CUSP Element)
Assess appropriateness of procedures that increase risk … Probabilistic risk assessment.
Causal tree worksheet. … In the context of cord prolapse, this includes risk awareness, timely recognition of a cord prolapse … of transition communication techniques assures a shared mental model of plan of care and perceived risks … Earlier studies, prior to the advent of continuous fetal monitoring, showed association with increased risks
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/timeline.html
December 01, 2014 - The facilitator reviews ways risk information is transmitted to clinical staff and ways care plans are … populated on the report to ensure that data on the report agree with staff knowledge of residents’ health/risks … The first report, Intervention History for Nutrition Risk Reports: High Risk and Medium Risk , focuses … on intervention history of residents with nutrition risks. … Intervention History for Nutrition Risk. Reports: High Risk and Medium Risk.
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-fac-guide.html
July 01, 2023 - processes, further aids in the development of high-quality patient care by allowing providers to mitigate risks … speaking up if they do not agree with task assignments and protocols or when they see patient safety risks … ratios exceed best practice based on the unit's acuity and rate of volume change, there is an increased risk … How will you reduce the risk of recurrence?
How will you know it worked?
-
www.ahrq.gov/news/blog/ahrqviews/world-patient-safety-day-2024.html
September 01, 2024 - Patients to Improve Diagnostic Safety —provide clinical teams and patients with resources to recognize risks
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-sustainability-centers-of-excellence6.html
April 01, 2025 - Guiding Questions for Windows of Opportunity How can the CE turn its knowledge of quality and safety risks
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www.ahrq.gov/hai/cauti-tools/impl-guide/implementation-guide-appendix-o.html
October 01, 2015 - Poster on Urinary Catheter Risks and Indications
Appendix F.
-
www.ahrq.gov/hai/tools/mrsa-prevention/toolkit/environmental-cleaning.html
February 01, 2025 - Involving Environmental Services staff in this process and encouraging their participation in identifying risks
-
www.ahrq.gov/hai/cauti-tools/archived-webinars/no-more-cauti-slides.html
December 01, 2017 - Inappropriate Catheter Indications
Patient of family request
Educate patient and family on catheter risks
-
www.ahrq.gov/sites/default/files/2024-01/thamer-report.pdf
January 01, 2024 - Public Health Advisory
Recently completed studies found an increased risk of death, blood clots, strokes … risks.” … ESA therapy has serious side
effects and might be associated with decreased survival and increased risk … oncology
patients was also released on March 2007 and included a mandate that providers engage
in a risk … The relative contribution of measured variables
to death risk among hemodialysis patients, Chapter 13