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ahrqpubs.ahrq.gov/patient-safety/settings/hospital/resource/qitool/index.html
March 01, 2017 - Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI Toolkit
Venous … Pressure Ulcer PDF [327 KB] PSI05 Foreign Body PDF [133.68 KB] PSI06 Pneumothorax PDF [130.62 KB] PSI07 Central … Venous Catheter-Related Bloodstream Infections PDF [150 KB] PSI08 Postoperative Hip Fracture PDF [ … PDI10 Postoperative Sepsis PDF [286.81 KB] PDI11 Postoperative Wound Dehiscence PDF [253.23 KB] PSI12 Central … Venous Catheter-Related Bloodstream Infections PDF [343.33 KB] NQI03 Neonatal Blood Stream Infection
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ahrqpubs.ahrq.gov/research/findings/making-healthcare-safer/comparison.html
September 01, 2022 - General Clinical Topics
Infection Control: Carbapenem-Resistant Enterobacteriaceae
Infection Control: Central … or Institutionalized Elders
Sepsis Recognition
Surgery, Anesthesia, and Perioperative Medicine
Venous … Infections
Patient Safety Practices
MHS I (2001)
MHS II (2013)
MHS III (2020)
Prevention of Central … Operating Room Integration and Display Systems
(Not reviewed)
Summary of Evidence
(Not reviewed)
Venous … Thromboembolism
Patient Safety Practices
MHS I (2001)
MHS II (2013)
MHS III (2020)
Prevention of Venous
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ahrqpubs.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - Implementation focused on MU Health Care’s 390-bed University Hospital, the only level I trauma center in central … Read the impact story: University of Chicago Medicine
UChicago Medicine reduced venous thromboembolism … patient population across their institution with the use of AHRQ’s Preventing Hospital-Associated Venous
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ahrqpubs.ahrq.gov/hai/pfp/2015-interim.html
December 01, 2016 - Tract Infections
270,000
8.2
CLABSIs
MPSMS (2015)
Blood Stream Infections Associated With Central … Venous Catheters
1,700
0.05
Falls
MPSMS (2015)
In-Hospital Patient Falls
220,000
6.7 … Antibiotic-Associated C. difficile
100,000
3.1
MPSMS (2015)
Mechanical Complications Associated With Central … Venous Catheters
80,000
2.4
MPSMS (2015)
Postoperative Cardiac Events for Cardiac and Non-Cardiac … Urinary Tract Infections
530,000
40%
50%
20%
106,000
$1,000
0.023
$106,000,000
2,470
Central
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ahrqpubs.ahrq.gov/funding/grantee-profiles/grtprofile-xiao.html
November 01, 2022 - The goal of that 4-year project was to understand and reduce risks of central line-associated bloodstream … Xiao identified frequent errors that occurred during the placement of central lines or central venous … Web-based training course with embedded video clips that demonstrated proper placement and how to avoid central
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ahrqpubs.ahrq.gov/news/newsroom/case-studies/202004.html
July 01, 2020 - The number of central line-associated bloodstream infections in intensive care units (ICUs) decreased … ChristianaCare also used CUSP to decrease the use of central venous (blood-line) catheters in its ICUs … TeamSTEPPS®,
Surveys on Patient Safety Culture
Topic(s):
Care Coordination,
Central
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ahrqpubs.ahrq.gov/news/newsletters/e-newsletter/814.html
May 01, 2022 - Study Identifies Barriers to Surveillance of Central Line-Associated Bloodstream Infections in Home Healthcare … Study Identifies Barriers to Surveillance of Central Line-Associated Bloodstream Infections in Home Healthcare … study highlights barriers that prevent home health workers from conducting successful surveillance of central … million patients receive home and specialty infusion services per year, typically for maintenance of central … Central venous catheter guidewire retention: lessons from England's never event database .
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ahrqpubs.ahrq.gov/patient-safety/resources/simulation/terms.html
June 01, 2022 - Some examples of this simulation work include inserting ultrasound-guided central venous catheters, diagnosing
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ahrqpubs.ahrq.gov/patient-safety/settings/hospital/index.html
March 01, 2024 - Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI Toolkit
Venous … Preventing Hospital-Associated Venous Thromboembolism: A Guide for Effective Quality Improvement outlines … the latest evidence on how to lead a quality improvement effort to prevent hospital-acquired venous … customizable, educational toolkit aims to help hospital intensive care units (ICUs) reduce rates of central
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/2017qdr-patsafchartbook.pdf
October 01, 2018 - thromboembolic events
• Bloodstream infection in adult patients receiving central venous catheter … Venous Catheters for Dialysis
• Importance: In hemodialysis patients, central venous catheters (CVCs … Hemodialysis patients age 18 years and over who had
central venous catheters used for vascular access … Hemodialysis patients age 18 years and over who had
central venous catheters used for vascular access … Bloodstream infection event (central line-associated bloodstream
infection and non-central line-associated
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a1c_combo_pdifactsheet.pdf
October 01, 2015 - PDI 10 Postoperative Sepsis Rate 14.33
PDI 11 Postoperative Wound Dehiscence Rate 1.12
PDI 12 Central … Venous Catheter-Related Blood Stream Infection Rate 0.76
PDI 13 Transfusion Reaction Count N/A
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ahrqpubs.ahrq.gov/hai/tools/abate/index.html
March 01, 2022 - Among non-ICU patients with specific medical devices (namely central venous catheters, midline catheters
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ahrqpubs.ahrq.gov/cpi/about/impact/index.html
April 01, 2017 - Hospital-acquired conditions have relatively high mortality risk and include central line-associated … blood stream infections, ventilator-associated pneumonia, and post-operative venous thromboembolism. … Comprehensive Unit-based Safety Program, or CUSP, at The Johns Hopkins Hospital, he nearly eliminated central … , process improvement, and teamwork, to more than 1,100 intensive care units nationwide and reduced central … AHRQ’s and other HHS investments have led to central line-associated blood stream infections declining
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ahrqpubs.ahrq.gov/patient-safety/settings/hospital/resource/qitool/webinar080116/index.html
December 01, 2017 - Measures: A Decision Guide
Communication and Optimal Resolution (CANDOR) Toolkit
Tools for Reducing Central … Retained Surgical item or Unretrieved Device Fragment
PSI 06: Iatrogenic Pneumothorax *
PSI 07: Central … Venous Catheter-‐Related Bloodstream Infection
PSI 08: In-‐Hospital Fall With Hip Fracture *
PSI … Respiratory Failure
PDI 10: Postoperative Sepsis
PDI 11: Postoperative Wound Dehiscence
PDI 12: Central … Venous Catheter-‐Related Bloodstream Infection
NQI 03: Neonatal Bloodstream Infection
* PDI 06
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.pdf
June 29, 2016 - PSI 06 Iatrogenic
Pneumothorax
0.5 0.6 1 $36,576 $ 36,576 N 2 1 1 Y Y Y Y Y
PSI 7 Central … Venous
Catheter-Related
Bloodstream
Infections
3.2 0.9 25 $82,147 $ 2,053,675 Y 10 10 8 Y … Postoperative
Wound Dehiscence
Rate
0.0 1.1 0 $76,737 $ - N 5 5 5 Y Y Y Y Y
PDI 12 Central … Venous Catheter-
Related Blood
Stream Infection
0.4 0.8 2 $121,010 $ 242,020 N 10 9 9 Y
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ahrqpubs.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/ap4.html
August 01, 2022 - Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI Toolkit
Venous … Central States Speech Journal 1982;33:333-8.
Burleson BR. Emotional support skills.
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4v_combo_pdi10-sepsis-bestpractices.pdf
May 17, 2016 - o Aim for end goals of pediatric sepsis resuscitation at central venous oxygen saturation
(ScvO2) greater … Normal pulses with no differential between peripheral and central pulses.
Warm extremities.
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ahrqpubs.ahrq.gov/news/blog/ahrqviews/womens-health-week-2023.html
May 01, 2023 - rising rates of severe maternal morbidity, eclampsia/preeclampsia, severe postpartum hemorrhage, and venous … most convenient to patients, and using “pop-up clinics” rather than expecting patients to travel to central
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b3a_combo_chartsforpresentations.xlsx
January 01, 2006 - 0.000187 0 0.000769 0.484 -99.9613636364 0.0386363636 0.1202479339 PSI 06 Statistically Lower 0
PSI 07 Central … venous catheter-related bloodstream infections 0.002408 0.00139 0.003477 0.752 -99.679787234 0.1353723404 … 0.0075716 0.00097 -100 -100 680.5773195876 PDI 11 No Statistically Significant Difference 0
PDI 12 Central … Venous Catheter-Related Blood Stream Infection Rate 0.0003802 0 0.0010654 0.001 -61.98 -100 6.54 PDI
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ahrqpubs.ahrq.gov/cpi/about/35th-anniversary/index.html
April 01, 2024 - projects include Your Guide to Preventing and Treating Blood Clots and Preventing Hospital-Associated Venous … Similarly, Michigan hospitals’ ICUs stopped central line-associated bloodstream infections for up to … Central line-associated bloodstream infections in newborns were reduced by 58 percent in less than a