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www.cpsi.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-slides.html
July 01, 2023 - Root Cause Analysis
Learn From Defects Form
Failure Mode and Effects Analysis
Probabilistic Risk … Worksheet
Discovery Form
Root Cause Analysis
Failure Mode and Effects Analysis
Probabilistic Risk … Discuss the three greatest risks.
Rank these factors. … Question 3: What will you do to reduce the risk of reoccurrence? … Sensemaking of patient safety risks and hazards. Hlth Svcs Res 2006;41(Aug 4 Pt 2.):1555-75.
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
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.cpsi.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/guide-prevent.html
May 01, 2017 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … multifaceted program covering all of the evidence-based strategies that have been shown to reduce the risks
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module3/module3_fall-prevention.docx
January 01, 2013 - Here are some other risks:
An IV pole could cause a patient to trip. … Slide 25
SAY: A risk score of 50 puts this patient at risk for a fall. … risks, such as mobility challenges, medications, mental status, and continence needs. … the patient and family (if possible), and key risks and interventions are checked on the paper tool shown … to have a dedicated care plan form within the medical record to help make staff aware of a patient’s risks
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www.cpsi.ahrq.gov/cpi/about/organization/nac/emert.html
March 01, 2024 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … conduct research and identify healthcare disparities, chronic disease trends, and infectious disease risks
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www.cpsi.ahrq.gov/patient-safety/settings/hospital/match/figure-2txt.html
July 01, 2022 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … High-Risk Situations for Medication Reconciliation
Conclusion
References
Appendix: The MATCH Work … Patient safety risks of documenting "resume home meds" not understated.
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/implementation-guide-making-informed-consent-informed-choice.pdf
January 01, 2017 - r You are at risk of malpractice lawsuits related to informed
consent. … Explain benefits, harms,
and risk of all options
X percent of patients will report that the description … ■ The principal risk of this survey is a small risk of loss of confidentiality. … The survey
team has many procedures in place to reduce this risk.
Who Spoke with You. … r I provide information on the test/treatment/procedure, risk/benefits, and
alternatives to patients
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www.cpsi.ahrq.gov/health-literacy/professional-training/shared-decision/workshop/mod3-guide.html
September 01, 2020 - These include when:
Choosing treatments—weighing risks and benefits. … instead of relative risk. … sense of personal or individual risk. … What Are the Risks of Having a Stent; 2013. … Communicating Risks and Benefits: An Evidence-Based User's Guide. U.S.
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www.cpsi.ahrq.gov/funding/process/study-section/resfoci.html
October 01, 2020 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … Innovation & Emergent Issues Research
Healthcare Safety and Quality Improvement Research (HSQR)
Identify Risks
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www.cpsi.ahrq.gov/prevention/curriculum/index.html
January 01, 2021 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … five-step process for shared decisionmaking that includes exploring and comparing the benefits, harms, and risks
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www.cpsi.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.cpsi.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/assessment.html
July 01, 2023 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … nonclinical staff (e.g., health unit coordinators and environmental services personnel) to find out what risks
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www.cpsi.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/communication/strategy6i-shared-decisionmaking.html
April 01, 2023 - These tools increase knowledge, improve risk estimates, increase patient's involvement in decisions, … benefited from an increased level of understanding that allowed discussions to focus on the critical risk … key 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.cpsi.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
July 01, 2023 - Probabilistic Risk Assessment.
Causal Tree Worksheet. … objective of this form is to access the knowledge at the frontlines of patient care to determine what risks … Discuss the three greatest risks.
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.cpsi.ahrq.gov/antibiotic-use/long-term-care/improve/index.html
September 01, 2021 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … techniques can help improve antibiotic use, as can fostering effective communication about the potential risks
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www.cpsi.ahrq.gov/patient-safety/settings/hospital/resource/guide/web6.html
December 01, 2017 - E nhance Services for High-Risk Patients. … Slide 9: High Risk Target Populations
There may be several target populations at high risk of readmission … Slide 10: Transitional Care for High-Risk Patients
Transitional Care for High-Risk Patients
Slide … Transitional Care Plan:
Identifies post-hospital needs, patient priorities, and readmission risks and … the plan to address those needs, priorities and mitigate risks in the 30 days post discharge.
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www.cpsi.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/pf-engagement-fac-notes.html
May 01, 2017 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … 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 … 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.cpsi.ahrq.gov/hai/tools/cauti-hospitals/index.html
March 01, 2018 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … to create or enhance a culture of patient safety can significantly decrease rates of CAUTI and other risks
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www.cpsi.ahrq.gov/research/findings/making-healthcare-safer/index.html
July 01, 2023 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … Health System , the seminal National Academy of Medicine report that elevated awareness of longstanding risks
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www.cpsi.ahrq.gov/talkingquality/translate/scores/framing.html
March 01, 2016 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … A negative frame would emphasize the risks of choosing a relatively poor performer.