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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b2b_combo_ratesgenbywin.pdf
March 01, 2016 - - 0.01018098
PDI10 PDI #10 Postoperative Sepsis Rate 0 0 - 0.01602384
PDI11 PDI #11 Postoperative Wound … - 0.00437031
PSI13 PSI #13 Postoperative Sepsis Rate 0 0 - 0.01180386
PSI14 PSI #14 Postoperative Wound … Rate – Injury to Neonate 0 0 - 0.00210694
PSI18 PSI #18 Obstetric Trauma Rate – Vaginal Delivery With … Thrombosis Rate
0.00437
PSI #13 Postoperative Sepsis Rate 0.011804
PSI #14 Postoperative Wound … Rate - Injury
to Neonate
0.002107
PSI #18 Obstetric Trauma Rate -
Vaginal Delivery With
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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/vol1/Advances-Schade_63.pdf
January 01, 2007 - family dissatisfaction 4.9
Administrative other/miscellaneous 4.9
Adverse clinical work-related injury … or exposure to
hospital staff
Blood and body fluid
exposure or
needlestick and
sharp injury or … physical injury report
The affected party was employee or staff 7 0.80 1.03 2.68 – 6.87 5.92
Omitted … Reported rates of
staff injury increased in all hospitals
statewide. … How much
work-related injury and illness is missed by the current
national surveillance system?
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ce.effectivehealthcare.ahrq.gov/patient-safety/quality-measures/qsrs/index.html
September 01, 2022 - events, e.g., not just fall rates over a given time, but also the percentage of falls that resulted in injury … and the rates of each specific type of injury.
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-3/guide.html
September 01, 2017 - CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure Injury … Post-Fall Huddles: Reducing Preventable Falls and Fall-Related Injuries —AHRQ Fall Prevention Program … The patient should be carefully and systematically assessed for injuries. … The post-fall clinical review focuses on immediate risk of injury or complications. … RCA is often used for a fall with injury.
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ce.effectivehealthcare.ahrq.gov/hai/cauti-tools/phys-championsgd/section4.html
October 01, 2015 - Acute urinary retention may be medication induced, medical (neurogenic bladder), or related to trauma … Assistance with healing of perineal and sacral wounds in incontinent patients. … Required immobilization for trauma or surgery. … Examples include an unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures … Common indications include respiratory failure, cardiac or pulmonary arrest, laryngeal trauma or edema
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/operroom.pdf
March 19, 2014 - At 2200, two
emergency trauma cases arrive. … Comments
This scenario demonstrates how managing resources can prevent inefficiency or potential
injury … chronic pain patient jumps from the hospital roof and sustains severe
and multiple life-threatening injuries … The trauma surgeons request access to the Operating Room (OR) for immediate laparotomy
and other repairs … This scenario demonstrates how cross-monitoring team members can help prevent error,
damage, or injury
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.xlsx
July 01, 2016 - 13 Postoperative Sepsis 12.7 11.7 15 $49,215 $ 738,225 N 9 7 3 Y Y Y Y Y
PSI 14 Postoperative Wound … Accidental Puncture or Laceration 3.2 3.3 1 $22,629 $ 22,629 Y 4 3 7 Y N Y Y Y
Obstetric PSI 17 Birth Trauma-Injury … to Neonate 0.0 0.1 0 $88,000 $ - 0 N 2 3 9 Y Y Y Y Y
PSI 18 Obstetric Trauma-Vaginal Delivery … With Instrument 134.8 135.1 17 $90,000 $ 1,530,000 N 2 3 8 Y Y Y Y Y
PSI 19 Obstetric Trauma-Vaginal … Postoperative Sepsis Rate 0.0 16.2 0 $117,815 $ - 0 N 9 10 10 Y Y Y Y Y
PDI 11 Postoperative Wound
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ce.effectivehealthcare.ahrq.gov/news/newsletters/e-newsletter/850.html
February 01, 2023 - care consultation offsets hospitalization duration and costs for elderly patients with traumatic brain injuries … : insights from a level 1 trauma center.
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2021qdr-appendixes.pdf
December 01, 2021 - 1,000 elective-surgery admissions of length 4 or HCUP 2018
Reclosure of postoperative abdominal wound … dehiscence per 1,000
2 or more days, adults
HCUP 2018
Home health care patients whose surgical wound … 2018
Home health
improved
care patients whose management of oral medications OASIS 2018
Birth trauma … - injury to neonate per 1,000 selected live births HCUP 2018
High-risk, long-stay nursing home patients … QUALITY MAP
Measure Title Data Source Data Year
Home health care patients whose surgical wound
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apii.html
June 01, 2010 - Effectiveness Reviews
Facilities
Home and Community Resources
Findings Report
Injuries
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/opioids/compendium/opioids-case-study-work-around.pdf
December 15, 2023 - note prompted clinicians to use a three-question version of the Stopping Elderly Accidents,
Deaths & Injuries
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ce.effectivehealthcare.ahrq.gov/patient-safety/reports/liability/sands.html
August 01, 2017 - The Massachusetts Alliance for Communication and Resolution following Medical Injury (MACRMI) was formed … Its goals are to (1) proactively identify adverse events, (2) differentiate between injuries caused by … an apology and rapid, fair compensation, with patient representation, when unreasonable care caused injury … models in the State: the Massachusetts Alliance for Communication and Resolution following Medical Injury … Errors, the Massachusetts Hospital Association, the Massachusetts Medical Society, and Medically Induced Trauma
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
June 01, 2021 - The resident not only had a heart attack but has developed a rash and acute kidney injury. … Stopping antibiotics would likely have prevented the development of a rash and acute kidney injury. … which was an allergic reaction to amoxicillin/clavulanic acid which led to a rash and acute kidney injury … aware of the laboratory results in a timely manner, the antibiotics were held, and the acute kidney injury
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/early-mobility-icu-facguide.docx
January 01, 2017 - These included: five falls to knees without injury, four with systolic blood pressure less than 90 mmHg … Slide 16
Early Mobility in a Trauma and Burns ICU
SAY:
Clark et al. performed a retrospective before … and after cohort study, based on chart review, at an academic medical center in a trauma and burns ICU … study focusing on the time to the first incidence of physical therapy for patients with acute lung injury … Slide 22
5-Year Sustainability of Time to PT Postacute Lung Injury Diagnosis
SAY:
In this chart you
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/implementation-guide/appendix-f.html
September 01, 2017 - Video monitoring has helped reduce falls and falls with injury. … Module 3: Best Practices in Fall Prevention
Hospital: >400 beds
Pilot Units: Ortho/Trauma, Medical … Implement the Fall Prevention Program in Your Organization
Hospital: >400 beds
Pilot Units: Ortho/Trauma … injury). … It looks at data for all falls, as well as for falls with injury.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-nh_webcast-castle.pdf
January 01, 2006 - Patient Safety Culture in Nursing Homes
• Safety culture influences staff as well as residents
► Overall injury
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursinghome-resourcelist.pdf
April 01, 2023 - Falls Management Program
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries … Provider Fax Report and Orders
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries … professionals/onthejob/falls.asp
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries … /fallspx/index.html
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspx … /fallspx/fallspxmanapb10pcp.html
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries
-
ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/orthostatic-vital-sign.html
January 01, 2013 - CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure Injury … Have possible spinal injuries.
Have lower extremity or pelvic fractures.
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ce.effectivehealthcare.ahrq.gov/research/findings/evidence-based-reports/search.html?page=32
August 01, 2007 - Preparedness
(19)
Quality Improvement and Patient Safety
(60)
Skin Conditions
(15)
Violence and Trauma … Ottawa Report Status: Final
Primary Care Interventions to Prevent Motor Vehicle Occupant Injuries
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/publications/files/psml-planning-grants-final-report.pdf
May 01, 2016 - the establishment of the Massachusetts Alliance for Communication and
Resolution following Medical Injury … All complaints involved some additional patient care and most
complaints (70%) resulted in some new injury … some new unanticipated
injury compared to non-IC/SDM complaints (35%; p = 0.001)” (Posner et al., 2013 … and establishment of the Massachusetts Alliance for Communication and Resolution
following Medical Injury … grievances to formal claims against Wishard alleging malpractice or other
actions leading to patient injury