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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/assemble/assemble-the-team.pptx
May 01, 2017 - Senior Executive Collaborates To Develop and Implement a Plan Addressing Safety Issues
Considers patient risks … identified in the staff safety assessment with team members
Involves frontline providers to help reduce risks … Psychological safety is the degree to which team members feel that their environment supports the interpersonal risk … Meet with hospital departments (risk management, quality improvement) to ensure that L&D CUSP efforts … Managing the Risk of Learning: Psychological Safety in Work Teams. In West M, ed.
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www.ahrq.gov/sites/default/files/2024-01/lo-report.pdf
January 01, 2024 - Additionally, risks of acute liver injury
were low among fluconazole, ketoconazole, and itraconazole … Pre-
existing chronic liver disease increased risks of aminotransferases >200 U/L (hazard ratio, 4.68 … In our study evaluating the comparative hepatic safety of azole antifungals,83 the absolute
risks and … Risks of acute liver injury were similarly low among users of fluconazole, ketoconazole,
and itraconazole … Managing the risks of from medical product use:
creating a risk management framework. http://www.fda.gov
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.docx
May 01, 2017 - 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?
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www.ahrq.gov/news/blog/ahrqviews/boost-health-services-research.html
June 01, 2022 - We risk witnessing patient and health professional safety events because of workforce depletion. … affordable, environmentally responsible, and protects patients and health professionals from safety risks
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www.ahrq.gov/news/blog/ahrqviews/public-health-emergency-refocus.html
May 01, 2023 - study 2 in the New England Journal of Medicine that estimated 1 in 4 people hospitalized are at risk … While these are reportable events, we can assume the risks are more widespread; safety events in many
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www.ahrq.gov/sites/default/files/2024-03/strom2-report.pdf
January 01, 2024 - Follow-up Study on CPOE and Medication Errors
A direct comparison of error-risks associated with old … 22 errors
risks, and reduced the likelihood of seven others. … However, nine error risks remained
unchanged, three were addressed but offsetting error risks emerged … , two error-reducing
functions were eliminated, and six new error risks were introduced. … The new CPOE remedied some of its
predecessor’s error risks, but several remain, and new ones were
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dx-leadership-cx.pdf
June 03, 2021 - B. 2015 CRICO Strategies National CBS Report: Malpractice Risks in Communication Failures. https://www.rmf.harvard … .
edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures. … https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures … https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dx-leadership.pdf
June 03, 2021 - B. 2015 CRICO Strategies National CBS Report: Malpractice Risks in Communication Failures. https://www.rmf.harvard … .
edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures. … https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures … https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures
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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
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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
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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
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www.ahrq.gov/ncepcr/reports/cost-guide/collection-tools.html
February 01, 2017 - Risks or discomforts: No risks or discomforts are anticipated.
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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.
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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
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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
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www.ahrq.gov/talkingquality/translate/scores/framing.html
March 01, 2016 - A negative frame would emphasize the risks of choosing a relatively poor performer.
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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
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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
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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
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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