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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/131-ss-swiss-cheese.pptx
April 01, 2025 - PowerPoint Presentation
Learning From Defects: Applying the “Swiss Cheese Model” of System Failures
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
AHRQ Pub. No. 25-0029
April 2025
AHRQ Safety Program for MRSA Prevention: Targeting SSI
AHRQ Safety Program for MRSA Prevent…
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www.ahrq.gov/sites/default/files/wysiwyg/chsp/compendium/techdocrpt-appf.pdf
January 01, 2019 - Comparative Health System Performance Initiative: Compendium of U.S. Health Systems, 2016, Technical Documentation-Appendix F
Comparative Health System Performance Initiative:
Compendium of U.S. Health Systems, 2016, Technical
Documentation
Prepared for:
Agency for Healthcare Research and Quality
U.S. Depar…
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hcup-us.ahrq.gov/db/nation/nis/APS-DRGsDefManualV27Public.pdf
April 01, 2010 - For
these DRGs, the presence of a CC assigned the discharge to a higher weighted DRG. … Only the standard discharge data elements that hospitals already
collect are needed. … Check that the patient’s discharge status is a valid inpatient UB-04 code. … Is
discharge status in the range 01 - 07, 20, 30, 43, 50, 51, 61 - 66? … Did the patient expire (i.e., discharge status equal to 20)?
If no, go to Step 7.
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digital.ahrq.gov/sites/default/files/docs/page/health-information-technology-evaluation-toolkit-2009-update.pdf
January 01, 2009 - Links
Inpatient
mortality
Patient Safety
Effectiveness
Medical records
Billing data
Discharge … ten tia l Ris ks Links
Length of stay Patient Safety
Efficiency
Medical records,
especially discharge … Consider external issues (e.g.,
financial pressures to discharge
patients early, other concurrent QI … For many
organizations, this
standard is 7 days
and/or 30 days after
inpatient discharge. … Examples include:
• Allergy on admission
• Follow-up plan on
discharge
• Care plan for next phase
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hcup-us.ahrq.gov/reports/statbriefs/sb261-Most-Expensive-Hospital-Conditions-2017.pdf
January 01, 2017 - rehabilitation, or treatment for a psychiatric or chemical dependency condition in a community hospital,
the discharge … Unit of analysis
The unit of analysis is the hospital discharge (i.e., the hospital stay), not a person … person who is admitted to the hospital multiple times in 1 year will be counted each time as a
separate discharge
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs021816-vawdrey-final-report-2018.pdf
January 01, 2018 - Potential influencers may be proximity to
admission/discharge or the observer effect.
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/carbapenem-resistant-1.pdf
March 01, 2020 - , 1.22, 95%
CI, 0.93 to 1.59, p=0.15), and extended length of stay
(standardized hazard ratio3 of discharge … Duration of carriage of carbapenem-resistant
Enterobacteriaceae following hospital discharge. … Outcomes:
Harms
Implementation
Themes/Findings
Risk of
Bias Comments
and lack of follow-up or
discharge … 3.50, p=0.79), in-
ICU death (SHR
1.22, 95% CI, 0.93
to 1.59, p=0.15),
and extended LOS
(SHR for discharge … specimen, 26.7%
discontinue after three
negative specimens
separated by 1 week, 53.3%
continue until discharge
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www.ahrq.gov/hai/cauti-tools/archived-webinars/patient-family-centered-care-transcript.html
December 01, 2017 - So, the challenge of communicating doesn't just involve patients and families when we're giving discharge … We also covered another area, like patient discharge instructions, which I thought was very important … because of the fact the way we looked at discharge papers and we laughed. … So, they were very considerate about that and we spoke about materials that should be in the discharge … Also, as far as like a medication list should be very clear in the discharge when you're leaving the
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/patient-family-centered-care-transcript.doc
April 09, 2013 - So, the challenge of communicating doesn't just involve patients and families when we're giving discharge … We also covered another area, like patient discharge instructions, which I thought was very important … because of the fact the way we looked at discharge papers and we laughed. … So, they were very considerate about that and we spoke about materials that should be in the discharge … Also, as far as like a medication list should be very clear in the discharge when you're leaving the
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Gershon_88.pdf
January 01, 2012 - nationwide campaign to reduce medical costs led to
3
decreased length of hospital stays and the early discharge … National
hospital discharge survey; 2003. Available at:
www.cdc.gov/nchs/data/ad/ad359.pdf.
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digital.ahrq.gov/sites/default/files/docs/citation/assessing-impact-of-pcmh-final-report.pdf
November 16, 2010 - and execution), expanded outpatient teams (especially nonclinical staff),
inpatient management and discharge … Re-hospitalization rates were calculated when there was hospitalization
within 30 days of discharge … Health outcome and utilization measures include
annual hospitalization rate, rate of live discharge, … Re-hospitalization rates were calculated when there was hospitalization within 30 days of discharge from … Health outcome and utilization measures include annual hospitalization rate, rate of live discharge,
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/sample-telephone-script.pdf
April 17, 2017 - Our records show that {SAMPLED CHILD NAME} was discharged from {HOSPITAL
NAME} on or about {DISCHARGE … [IF {ANY DATE} WAS WITHIN TWO WEEKS OF {DISCHARGE DATE}, GO TO
1_INTRO; OTHERWISE, GO TO INTEL_END.] … registros indican que a {SAMPLED CHILD NAME} lo/la dieron de alta del
{HOSPITAL NAME} más o menos el {DISCHARGE … [IF {ANY DATE} WAS WITHIN TWO WEEKS OF {DISCHARGE DATE}, GO TO
1_INTRO; OTHERWISE, GO TO INTEL_END.]
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2021qdr-appendixes.pdf
December 01, 2021 - the last
the care they received
2 months of care
from HHCAHPS 2019
Adult hospital patients
discharge … their preferences and those of their family and caregiver into account
when deciding what the patients discharge … and family
definitely recommend this hospice to HOSPICE
CAHPS
2019
Adult hospital patients
discharge … their preferences and those of their family and caregiver into account
when deciding what the patients discharge
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hcup-us.ahrq.gov/reports/ataglance/HCUPanalysisInjuryReporting.pdf
September 29, 2021 - Hospital discharge data can be used to identify significant injuries that are priority
targets for prevention … The HCUP State Inpatient Databases (SID) contain the universe of the inpatient discharge abstracts from … The SID contain clinical and resource-use information that is included in a typical discharge abstract … nonclinical variables, such as:
• Principal and secondary diagnoses and procedures
• Admission and discharge
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www.ahrq.gov/research/shuttered/toolkitchecklist/surgetkit2.html
July 01, 2018 - Facilities
Public Health Emergency Preparedness
1. Preplanning
Description: Certain equipment, services, or staffing required for surge use of the shuttered hospital will necessitate advance arrangements, including identification of providers, contracts, specifications, and protocols.
Timeframe: As soon…
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www.ahrq.gov/sites/default/files/2024-01/lapane-report.pdf
January 01, 2024 - We excluded people younger than 65 (733 individuals) and people with a missing
discharge date, a discharge … date before October 2003, or inconsistent admit and discharge
dates (179 individuals). … Delirium is resolved in only 4% at discharge, 21% by 3 months,
and 18% by 6 months, with the remainder
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hcup-us.ahrq.gov/reports/SOI.jsp
June 01, 2016 - HCUP Supplemental Files
NIS-Trend Weights Files
NIS Hospital Ownership Files
NIS 1993-2002 Discharge-Level … For example, hospital administrative discharge abstracts or medical records typically do not capture … a patient's level of functioning at admission or discharge. … disorders were grouped into three ordinal categories of functional severity for use with administrative discharge
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/booklets/gynecologic-booklet.pdf
November 01, 2023 - .................................................................21
Plan for Leaving the Hospital (Discharge … ■ You’ll meet with a case manager or discharge planner to figure out if a nurse
should visit you … 24 AHRQ Safety Program for Improving Surgical Care and Recovery
Plan for Leaving the Hospital
(Discharge … Three Days After Surgery
You May Need To Stay in the Hospital Longer
Plan for Leaving the Hospital (Discharge
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/peripheral-nerve-block-protocol.pdf
November 18, 2023 - periods of interest as acute (within 72 hours of surgery or during the inpatient stay),
subacute (discharge … research would be focused on acute outcomes, and that there will likely be little
reported on post-discharge … liposomal/long-acting local anesthetic)
Outcomes Early//intermediate (72 hours or time of
discharge … Outcome
Timing
Post-operative period ≤3 months subdivided into
72 hours or less; >72 hours or discharge
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effectivehealthcare.ahrq.gov/sites/default/files/product/pdf/respectful-maternity-care-protocol.pdf
September 16, 2022 - Inclusion Exclusion
Population KQ 1-4: Pregnant adolescents and adults
admitted for labor through discharge … Harms
• Utilization outcomes for pregnant persons
o Length of stay
o Healthcare utilization post-
discharge … mortality
o Harms
• Utilization outcomes for infants
o Length of stay
o Healthcare utilization post-
discharge … • KQ4: Infant health outcomes >1
year
Timing • Intervention: Admission for labor through
discharge