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teamstepps.ahrq.gov/hai/pfp/methods.html
December 01, 2017 - Surgeries
MPSMS
Postoperative Pneumonia
PSI
Iatrogenic Pneumothorax (PSI 6)
PSI
Post-Op Hemorrhage … 32,750,000
2.959
PSI
Iatrogenic Pneumothorax (PSI 6)
13,490
32,750,000
0.412
PSI
Post-Op Hemorrhage
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teamstepps.ahrq.gov/funding/grantee-profiles/grtprofile-halamek.html
August 01, 2023 - of the umbilical cord has been shown to decrease rates of iron deficiency anemia, intraventricular hemorrhage … (bleeding inside or around the brain), and blood transfusion.
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teamstepps.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/labordel.pdf
March 18, 2014 - The baby dies from ventricular
hemorrhage caused by trauma. … for: L&D
Setting: Hospital
Denise Whitaker, a 36-year-old G2 P1 with a history of a postpartum hemorrhage … Carol McCarthy, a 32-year-old Gravida 4 Para 2 patient is admitted to labor and delivery with
vaginal bleeding … An exploratory
laparotomy reveals massive intra-abdominal hemorrhage requiring a hysterectomy and blood … The placenta does not detach, the uterus fails to
contract, and massive hemorrhage ensues.
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teamstepps.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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teamstepps.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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teamstepps.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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teamstepps.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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teamstepps.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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teamstepps.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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teamstepps.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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teamstepps.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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teamstepps.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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teamstepps.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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teamstepps.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/2017qdr-patsafchartbook.pdf
October 01, 2018 - • Postoperative hemorrhage or hematoma with surgical drainage or evacuation per 1,000
surgical hospital … for cardiac and noncardiac surgery, postoperative pneumonia, iatrogenic pneumothorax, postoperative
hemorrhage … for cardiac and noncardiac surgery, postoperative pneumonia, iatrogenic pneumothorax, postoperative
hemorrhage … The three initial targets of the HHS National Action Plan for Adverse Drug Event Prevention are:
Bleeding … Anticoagulants, such as warfarin,
reduce this risk but pose an increased risk of bleeding.
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teamstepps.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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teamstepps.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