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www.ahrq.gov/hai/tools/mrsa-prevention/surgery/cusp-mrsa-prevention.html
April 01, 2025 - Premortem Assessment The Premortem Tool is a proactive way to anticipate risks and failures before they
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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/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Cotayo.pdf
April 22, 2004 - To reduce these behaviors also mitigates considerable safety risk. … patient’s imminent harm
to self or others and, increasingly, few who do not present either of these risks … in the
period).8
Psychiatric hospitalization may also impose more subtle, less immediate
safety risks … in work, school, and social settings are less likely
to experience deterioration and the attendant risks … the community in the course of a year versus in an acute care setting with its
concomitant safety risks
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www.ahrq.gov/patient-safety/reports/hotline/appd.html
May 01, 2016 - Communications
Patient Relations and or Patient/Family Advisory Council members/VP Patient Experience
Legal/Risk … Probe: [ASK EVERYONE BUT ESPECIALLY RISK MANAGEMENT] What about involving legal or risk management? … Can you tell us anything about what risks were identified? Any concerns that emerged? … ]
Very encouraging
Somewhat encouraging
Neutral
Somewhat discouraging
Very discouraging
ASK RISK … MANAGEMENT, LEGAL, AND HUMAN-SUBJECTS RESPONDENTS ONLY:
Knowing what you know now about the risks
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/hotline/healthcare-safety-hotline-appendixd.pdf
February 01, 2014 - Legal/Risk Management
7. … Probe: [ASK EVERYONE BUT ESPECIALLY RISK MANAGEMENT] What about
involving legal or risk management? … Can you tell us anything about what risks were identified?
Any concerns that emerged?
3. … Very encouraging
Somewhat encouraging
Neutral
Somewhat discouraging
Very discouraging
ASK RISK … Knowing what you know now about the risks, legal environment, and privacy issues, and
once the research
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www.ahrq.gov/news/newsroom/case-studies/cquips0901.html
October 01, 2014 - "We are striving to create a culture where staff feels comfortable and compelled to report risks to patient
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/communication/cahps-strategy-section-6-i.pdf
July 01, 2017 - These tools increase
knowledge, improve risk estimates, increase patient’s involvement in decisions, … Shared Decision-Making
July 2017 6.I-3
discussions to focus on the critical risk/benefit tradeoffs … to success lies in training physicians and other members of the
care team to:
communicate about risks … expressed needs when making
recommendations for care.18
Clinical decision support tools, such as risk … can follow-up with patients to
determine whether they understood that they had options, how much the risks
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/family-slides.pptx
June 01, 2021 - Exposure to antibiotics also puts your mom at risk for developing a future infection with resistant bacteria … Sometimes we start treatment here, but even oral medications have risks and side effects.”
23
Discussing … Points
Effective communication is a key component
Educating residents and family members about the risks
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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/hai/cauti-tools/ena-slides/part2.html
October 01, 2020 - catheterized would save time, but clearly, with extended lengths of stay, infection complications, and other risks … Slide 77
Saves time for the bedside nurse:
With infection complications, extended stay and other risks
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www.ahrq.gov/research/findings/final-reports/index.html?page=21
January 01, 2024 - Pediatrics, Teamwork and Leadership Publication Date: August 2003
How Do Consumers View the Risks
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/pf-engagement-fac-notes.html
May 01, 2017 - An informed consent includes the risks and benefits of the procedure and must be fully explained so that … consent process is an opportunity to not only inform the patient and their family about the possible risks … A patient may consent to a procedure without having a full understanding of the risks involved, especially … Risks, benefits, and alternatives should be explained using terms and language understood by the patient … In some facilities, this requires reporting to the patient’s physician, risk management department, and
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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/sites/default/files/2024-01/abraham-report.pdf
January 01, 2024 - thromboembolism, or post-acute coronary syndrome using
administrative data, studying heterogeneity of risks … PURPOSE/STUDY OBJECTIVES
Aim 1: To determine how GIB risk (total-, upper- and lower-GIB risk) among … Our
study results demonstrate that these risks may be similar, and, in some individuals, the
use … approaches to mitigate risk. … claims data of ACS patients following PCI,
we discovered that ticagrelor was associated with a 25% relative
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_sustscorecard.pptx
December 01, 2017 - Consider participating in surgical morbidity and mortality conferences
Post the stories of reduced risks … Post the stories of the reduced risks, along with your data within your hospital network.
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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.
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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