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ce.effectivehealthcare.ahrq.gov/sops/bibliography/index.html?page=1
January 01, 2024 - Effect of an obstetric hemorrhage bundle on clinical outcomes and clinician perceptions.
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/resource/qitool/webinar080116/index.html
December 01, 2017 - Related Bloodstream Infection
PSI 08: In-‐Hospital Fall With Hip Fracture *
PSI 09: Perioperative Hemorrhage … NQI 01: Iatrogenic Pneumothorax
PDI 06: Pediatric Heart Surgery Mortality *
PDI 08: Perioperative Hemorrhage
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ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-reimagining-healthcare-teams-refs.html
July 01, 2023 - Evaluation of risk stratification schemes for ischaemic stroke and bleeding in 182 678 patients with … Utilization of artificial intelligence-based intracranial hemorrhage detection on emergent noncontrast
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ce.effectivehealthcare.ahrq.gov/hai/cusp/modules/understand/science-safety-notes.html
July 01, 2018 - example from an obstetrics unit, staff received standardized education on the prevention of post-partum hemorrhages … and teamwork components in the following examples from the video:
Using daily goals,
Post-partum hemorrhage
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/physician-staff-engagement-slides.pptx
January 01, 2017 - related to outcomes
Patient outcomes
Patient care experiences
Rates of infection and sepsis
Postoperative hemorrhages
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/afib_topicref.pdf
January 01, 2020 - by patient-level characteristics such as age, sex, type of AF, comorbidities, risk for stroke or
bleeding … Prior rate- or rhythm-control
pharmacological strategy was ineffective
o High risk for stroke or bleeding … infarction
• Procedural complications (pulmonary vein
stenosis, atrioesophageal fistula, major
bleeding … complications/hemorrhage, phrenic
nerve palsy, pericardial effusion or cardiac
tamponade, deep vein … hepatotoxicity, neurotoxicity, pulmonary
toxicity, ophthalmological toxicity,
dermatological toxicity)
• Hemorrhage
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/Updated-hacreportFInal2017data.pdf
July 01, 2020 - Noncardiac Surgeries
MPSMS Postoperative Pneumonia
PSI Iatrogenic Pneumothorax (PSI 6)
PSI Post-Op Hemorrhage … Iatrogenic
Pneumothorax
7,372 18,948,556 5,472 25,363,956 4,852 25,536,803
PSI 9, Perioperative
Hemorrhage … PSI Iatrogenic
Pneumothorax
10,674 0.36 9,694 0.33 9,688 0.33 8,525 0.29
(PSI 6)
PSI Post-Op
Hemorrhage
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/physician-staff-engagement-facguide.docx
January 01, 2017 - is linked to worse patient outcomes, including an increase in infection rates, sepsis, postoperative hemorrhage
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ce.effectivehealthcare.ahrq.gov/research/findings/final-reports/ptflow/section3.html
April 01, 2020 - Skip to main content
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
May 20, 2016 - IQI 16 Heart Failure Mortality Rate
• IQI 17 Acute Stroke Mortality Rate
• IQI 18 Gastrointestinal Hemorrhage
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0198-fullreport.pdf
November 01, 2019 - o Trauma such as skull fracture, concussion, intracranial hemorrhage, and suspected abuse. … , hemangioma, phlebitis/thrombophlebitis,
occlusion of cerebral arteries, moyamoya disease, tumor, hemorrhage … complex febrile seizure; post-traumatic seizure; trauma such as skull
fracture, concussion, intracranial hemorrhage … , hemangioma, phlebitis/thrombophlebitis, occlusion of cerebral arteries,
moyamoya disease, tumor, hemorrhage
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hacreport-2019.pdf
January 01, 2019 - Noncardiac Surgeries
MPSMS Postoperative Pneumonia
PSI Iatrogenic Pneumothorax (PSI 6)
PSI Post-Op Hemorrhage … Adverse Events for This Measure
PSI 6, Iatrogenic Pneumothorax 7,372 18,948,556
PSI 9, Perioperative Hemorrhage … PSI Iatrogenic
Pneumothorax
10,674 0.36 9,694 0.33 9,688 0.33 9,688 0.33
(PSI 6)
PSI Post-Op
Hemorrhage
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/natlhacratereport-rebaselining2014-2016_0.pdf
January 01, 2016 - Noncardiac Surgeries
MPSMS Postoperative Pneumonia
PSI Iatrogenic Pneumothorax (PSI 6)
PSI Post-Op Hemorrhage … MPSMS Postoperative Pneumonia 88,015 2.96
PSI Iatrogenic Pneumothorax (PSI 6) 10,674 0.36
PSI Post-Op Hemorrhage … 2.17
PSI Iatrogenic
Pneumothorax (PSI
6)
10,674 0.36 9,694 0.33 9,694 0.33
PSI Post-Op
Hemorrhage
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/resource/nicu/packet/apb2.html
December 01, 2013 - Peri- or intraventricular hemorrhage, periventricular leukomalacia, necrotizing enterocolitis, retinopathy … Large granulomas may cause bleeding, aphonia, and accidental decannulation. … Bleeding:
Tip of tube may irritate tracheal wall, causing irritation, inflammation, and ulceration. … Anterior wall erosion can invade innominate artery, causing catastrophic hemorrhage. … Bleeding (28%).
Pain (65%).
Requiring silver nitrate (56%).
Broken or leaky tube (56%).
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ce.effectivehealthcare.ahrq.gov/es/patient-safety/settings/hospital/resource/nicu/packet/apb2.html
December 01, 2013 - Peri- or intraventricular hemorrhage, periventricular leukomalacia, necrotizing enterocolitis, retinopathy … Large granulomas may cause bleeding, aphonia, and accidental decannulation. … Bleeding:
Tip of tube may irritate tracheal wall, causing irritation, inflammation, and ulceration. … Anterior wall erosion can invade innominate artery, causing catastrophic hemorrhage. … Bleeding (28%).
Pain (65%).
Requiring silver nitrate (56%).
Broken or leaky tube (56%).
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/assess-psc-hsop-facguide.docx
January 01, 2017 - hospitals with a better safety culture tend to have lower rates of infection, sepsis, postoperative hemorrhage
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Rojas.pdf
March 15, 2004 - percent of cases experiencing an
adverse occurrence, the most frequent were unplanned (re)operation,
hemorrhage … occurrences No. %
Unplanned operation or reoperation related to the primary procedure 270 17.5
Hemorrhage … repair 21 1.4
Unplanned laparoscopic conversions to an open procedure because
of an injury and/or bleeding
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ce.effectivehealthcare.ahrq.gov/downloads/pub/advances/vol1/Schillinger.pdf
January 01, 2004 - international normalized ratio (INR) values either were <
2.0 (at risk for thrombosis) or > 4.0 (at risk for hemorrhage … them at risk for serious, preventable complications such as
stroke (if under-anticoagulated)3, 4 and bleeding … associated with increased risks of adverse
events,4, 37 such as thrombotic events (under-treatment) or bleeding … over-anticoagulation, each of which has been shown to be related to adverse
outcomes such as stroke and bleeding
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Kravitz.pdf
February 09, 2005 - By the time they are seen in
the outpatient setting, they may already be bleeding. … unrestrained optimism, let us even assume
that WARFDOCS is associated with a decrease in the rate of major hemorrhage … Major bleeding after
hospitalization for deep-venous thrombosis. … Risk of major
hemorrhage for outpatients treated with warfarin. … Guideline-based
consultation to prevent anticoagulant-related bleeding.
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ce.effectivehealthcare.ahrq.gov/hai/tools/mvp/modules/cusp/physician-staff-engagement-slides.html
March 01, 2017 - Postoperative hemorrhages.
Respiratory failure.
Patient injury.
Treatment errors.