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talkingquality.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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talkingquality.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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talkingquality.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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talkingquality.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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talkingquality.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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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/rapid-response/tool_rapidresponse-systems.docx
May 01, 2017 - deterioration
Specific activation criteria:
· Category III fetal heart rate tracing
· Bright red vaginal bleeding … specific activation criteria include—
· Category III fetal heart rate tracing
· Bright red vaginal bleeding … FHR tracing
_____________________
_____________________
Cord prolapse
Shoulder dystocia
Vaginal hemorrhage
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talkingquality.ahrq.gov/hai/pfp/2014-final.html
January 01, 2018 - 71,000
2.2
PSI (2014)
Iatrogenic Pneumothorax (PSI 6)
12,000
0.36
PSI (2014)
Post-Op Hemorrhage
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014FinalHACreport4Web-13Dec2016.pdf
December 01, 2016 - Pneumonia
71,000 2.2
PSI (2014) Iatrogenic
Pneumothorax (PSI
6)
12,000 0.36
PSI (2014) Post-Op Hemorrhage
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talkingquality.ahrq.gov/hai/pfp/2015-interim.html
December 01, 2016 - 51,000
1.6
PSI (2014)
Iatrogenic Pneumothorax (PSI 6)
12,000
0.37
PSI (2014)
Post-Op Hemorrhage
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talkingquality.ahrq.gov/patient-safety/resources/learning-lab/index.html
February 01, 2024 - Results included a reduced mortality rate of patients with atraumatic intracerebral hemorrhage (ICH) … or subarachnoid hemorrhage (SAH) from 29 percent before intervention to 11 percent postintervention.
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/psml-planning-grants-final-report.pdf
May 01, 2016 - clinician input, the grantee identified four obstetric clinical events—shoulder dystocia,
postpartum hemorrhage … section, White women rather than Black women,
and drug overdose played a greater role in deaths than hemorrhage
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module3/module3_tools.docx
January 01, 2012 - Postfall Assessment, Clinical Review
Note: There is increased risk of intracranial hemorrhage in patients … check all that apply
Injury
Yes
No
Site of Injury
Abrasion/bruise/laceration/hematoma
Bleeding
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/topics/defining-diagnostic-error-a-scoping-review.pdf
April 27, 2022 - Misdiagnosis of cerebellar
hemorrhage—features of ‘pseudo-gastroenteritis’ clinical presentations to
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talkingquality.ahrq.gov/sites/default/files/publications/files/hacrate2013_0.pdf
October 01, 2015 - Pneumonia
65,000 2.0
PSI (2013) Iatrogenic
Pneumothorax (PSI 6)
12,000 0.37
PSI (2013) Post-Op Hemorrhage