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ce.effectivehealthcare.ahrq.gov/talkingquality/translate/labels/describe.html
January 01, 2023 - General Hospital (MGH) URL: https://www.massgeneral.org/quality-and-safety/patient-safety/pressure-injury-prevalence … complete information, go to https://www.massgeneral.org/quality-and-safety/patient-safety/pressure-injury-prevalence … that nurses have the necessary knowledge for skin assessment and intervention they attend a Phase I Wound
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/index.html
March 01, 2017 - Effectiveness Reviews
Facilities
Home and Community Resources
Findings Report
Injuries
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/action-alliance/action-alliance-rfi-report-040323_LOCKED.pdf
March 01, 2023 - Administration (OSHA)
o ECRI
o Workplace Change Collaborative – National Framework on Burnout and Moral Injury … “By and large, the U.S. does not account for medical care injuries and deaths in our vital
statistics … Where it should
say 'medical care harm/injuries,' it's blank. … Administration (OSHA)
o ECRI
o Workplace Change Collaborative – National Framework on Burnout and Moral Injury … “By and large, the U.S. does not account for medical care injuries and deaths in our vital statistics
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/incident-reports.html
January 01, 2013 - CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure Injury … Type of injury
Be specific, e.g., "fractured tibia," not "broken leg." … If a fall from bed, whether bedrails were in use
Help assess how bedrail use is affecting falls or injury
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevhospitalvisits-funcspecs_0.pdf
August 01, 2017 - then display X in Wound
• Infected wound or decubitus ulcer
• Jaundice
• Rash
10 Injury: Fall … Related
Transfer
Note
•
•
Major injury
Minor injury
IF either selected, then display
Fall … X in Injury:
11 Injury: Non-
Fall Related
Transfer
Note
•
•
Major injury
Minor injury
IF … Cardiac/Circulatory Major injury
Anemia Minor injury
Cardiac arrest
Coagulation defect … Chest pain/angina
Dizzy/lightheaded
Non-Fall-Related Injury
Major injury
Minor injury
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ce.effectivehealthcare.ahrq.gov/funding/grantee-profiles/grtprofile-walsh.html
October 01, 2023 - received a 3-year AHRQ grant in 2015 to identify the factors that contribute to medication error and injury … Nephrotoxic medicines, such as contrast dye or nonsteroidal anti-inflammatory drugs, can cause acute kidney injury … She developed a customized prototype based on the AHRQ-funded Nephrotoxic Injury Negated by Just-in-Time
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/otimefallspx-implmatls.pdf
November 02, 2017 - taking measures to prevent further falls in those who have had a
previous fall/falls (with or without injury …
If the activity was unusual for the resident
Interviews with witnesses
Body check for injury … Initiative for Nursing Facilities,
http://www.ahrq.gov/professionals/systems/long-term-
care/resources/injuries … www.fallpreventiontaskforce.org/
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries … /fallspx/fallspxmanual.pdf
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries
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ce.effectivehealthcare.ahrq.gov/topics/childrenadolescents.html
January 01, 2011 - Home
University of Iowa Uses AHRQ Data to Study Ways to Lower Incidence, Costs of Sports-Related Injuries
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ce.effectivehealthcare.ahrq.gov/topics/index.html?page=1
January 01, 2012 - Falls can lead to serious injuries, decreased ability to function, reduced quality of life, increased
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ce.effectivehealthcare.ahrq.gov/topics/outcomes.html
Reduces Emergency Wait Time, Adverse Events Using AHRQ Tools
Connecticut Hospital Reduces Pressure Injuries
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a1b_combo_psifactsheet.pdf
October 01, 2015 - Thrombosis Rate
4.99 0450 2012
PSI 13 Postoperative Sepsis Rate 9.61
PSI 14 Postoperative Wound … Laceration Rate X 1.89 0345 2012
PSI 16 Transfusion Reaction Count X N/A* 0349 2012
PSI 17 Birth Trauma … Rate – Injury to Neonate 1.89
PSI 18 Obstetric Trauma Rate – vaginal delivery
with instrument … 133.19
PSI 19 Obstetric Trauma Rate – vaginal delivery
without instrument
20.97
PSI 90
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK2_T4-Common_Suspected_Infections_Tools_to_Improve_Communication_and_Decision_Making.ppt
May 01, 2014 - In wound infections among soldiers in the Middle East, multidrug resistant acinetobacter infections have … problem
Vital signs
Usual cognitive function
Recent/current health status (including falls)
Falls, minor injury … : require on-site first aid treatment (dressing, ice pack, pain medication)
Falls, serious injury: require … does not have COPD
- suspected or proven influenza in the absence of a secondary infection
- a skin wound … mobility (passive or active)
Acetaminophen 650 mg as needed or prior to cleaning/dressing changes
Cleanse wounds
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Davis_60.pdf
April 07, 2008 - failure modes and effects analysis (FMEA) is a widely used technique for assessing
risk of patient injury … Introduction
Catastrophic patient injury often occurs because of an unanticipated sequence of active … becoming widespread and has been developed for
numerous applications.9, 10, 11 Catastrophic patient injury … ) to “major
injury” to “death.” … Preventing infant death and injury during delivery.
Sentinel Event Alert.
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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 - These elements were wound
dehiscence requiring repair, displacement/migration/ breakage of implant, … thrombosis requiring repair, postoperative wound infection, wrong patient/site,
incorrect procedure … Adverse events have
been defined as “an injury that was caused by medical management (rather than
the … Excess length of stay, charges and
mortality attributable to medical injuries during
hospitalization … Looking for medical injuries
where the light is bright. JAMA 2003;290(14):1917–9.
22.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/putoolkit_module5_tools.docx
August 02, 2017 - stakeholders and staff
Root cause analysis is conducted for each fall with at least moderate level of injury
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxsamplereports.pdf
November 06, 2017 - cognitively impaired
Other, please describe
Fall Comments Free text
Fall Injury … Yes/no N N Y Y Y N
On-Time Falls Prevention: Electronic Reports 14
If yes, what type of
injury … Injury Type: Major Fracture: hip X
Fracture: other
Joint dislocation
Closed head … injury with altered consciousness
Subdural hematoma
Injury Type: Minor Skin tear X … that causes pain
Injury Site Head
Upper extremity (UE)
Lower extremity (LE)
LE LE LE LE
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ce.effectivehealthcare.ahrq.gov/patient-safety/reports/engage/appc.html
March 01, 2017 - ti])) OR iatrogenesis [ti] OR iatrogenic [ti] OR ((medical [ti] OR treatment [ti] OR care [ti]) AND (injury … [ti] OR injuries [ti])) OR mishap* [ti] OR (root [ti] AND cause* [ti]) OR (failure* [ti] AND mode* [
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ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-01/bates-report.pdf
January 01, 2024 - brought it to the forefront of public attention.1 The
IOM report estimated that more than a million injuries … that many patients annually are injured as a result of medications.3;4
Furthermore, many of these injuries … developing systems
that prevent and buffer errors, we gathered information about the types and causes of
injuries … The most common injuries resulting from ADEs were
cardiovascular, especially hypotension, defined as … challenges as well as uncertainty about how effective the systems actually
are for reducing drug-related injuries
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/one-pager-aspiration-pneumonia.docx
June 01, 2021 - Aspiration Pneumonia
· Aspiration pneumonitis is an abrupt chemical injury … an aspiration event.4
Aspiration Pneumonitis
Aspiration Pneumonia
Pathophysiology
Acute lung injury
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/menu.html
December 01, 2017 - Effectiveness Reviews
Facilities
Home and Community Resources
Findings Report
Injuries … Wound rounds
4. Weekly wound review meetings
5. Skin rounds
6. … Weekly wound review meetings
4. Internal nutritional review
5. … Wound rounds
2. Weekly nutrition-at-risk meetings
3. … Weekly wound review meetings
5. Restorative care review
6.