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pbrn.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/ldu-safety-slides.html
July 01, 2023 - Effects of shoulder dystocia training on the incidence of brachial plexus injury. … Shoulder dystocia and injuries: prevention and management.
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pbrn.ahrq.gov/patient-safety/reports/advancing/index.html
July 01, 2022 - private-public partnerships to: (1) identify the causes of preventable health care errors and patient injury … Education in 2003 and that the long shifts medical interns worked led to 61 percent more needlestick injuries
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pbrn.ahrq.gov/patient-safety/settings/hospital/red/toolkit/index.html
April 01, 2023 - CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure Injury
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pbrn.ahrq.gov/sites/default/files/publications/files/universalicu.pdf
September 01, 2013 - Wound Care
1. For what types of wounds is chlorhexidine (CHG) application safe? … #2: Nasal Trauma
Do NOT use mupirocin if nostril(s) are packed. … or superficial
wound … CHG will not harm occlusive dressing (e.g., wound vacs).
Do NOT use on large or deep wounds … CHG can cause
permanent injury if it comes in direct contact with nerves and is allowed to remain there
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pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes2.html
August 01, 2022 - CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure Injury
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pbrn.ahrq.gov/cpi/about/35th-anniversary/index.html
April 01, 2024 - show that national efforts to reduce hospital-acquired conditions, such as adverse drug events and injuries
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety.pptx
May 01, 2017 - Effects of shoulder dystocia training on the incidence of brachial plexus injury. … Shoulder dystocia and injuries: prevention and management.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/simulation/simslides-update-62819.ppt
January 30, 2006 - chunks
Embed triggers into these chunks
TEAMSTEPPS 05.2
Mod 1 05.2 Page *
Page *
Simulation
Trauma … Example
Pre-Hospital/Transport
Trauma Phase
Event Set Triggers Expected Team
Behaviors
Pre-Hospital … known information
Communication
Team members use call-outs and check-backs to share accurate patient injury … information has not been provided
TEAMSTEPPS 05.2
Mod 1 05.2 Page *
Page *
Simulation
Trauma … Example
Primary Survey
Trauma Phase Trigger Expected Team
Behaviors
Primary Survey Too many people
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/pfphac.pdf
September 01, 2014 - With Central Venous Catheters
Falls MPSMS In-Hospital Patient Falls
Obstetric Adverse Events PSI OB Trauma … The national number of adverse events captured by PSIs 18 and 19 on obstetric injury, and the
national … Falls MPSMS In-Hospital Patient Falls 262,317 32,750,000 8.010
Obstetric
Adverse Events
PSI OB Trauma
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pbrn.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu1.html
October 01, 2014 - CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure Injury … For example, does the organization have a certified wound care nurse? … If not, who has lead responsibility for wound care? … These individuals would be from various disciplines and may include physicians, unit managers, wound … In developing the list, consider the resources already in place, such as wound care nurses, data system
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pbrn.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/hp/Child_Med_Eng_HP51_2155a.pdf
October 01, 2020 - In the last 6 months, did your child have an
illness, injury, or condition that needed
care right away
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/natlhacratereport-rebaselining2014-2016_0.pdf
January 01, 2016 - patient safety events, including
many types of hospital-acquired infections, adverse drug events, and injuries … Infections
Clostridium difficile
Infections
Falls
Obstetric Adverse
Events
Pressure
Ulcers/Pressure Injuries … Central Venous Catheters
Falls MPSMS In-Hospital Patient Falls
Obstetric
Adverse
Events
PSI OB Trauma … National number of adverse events captured by PSIs 18 and 19 on obstetric
injury and national number … 8,513 0.29
Falls MPSMS In-Hospital Patient Falls 238,965 8.03
Obstetric
Adverse
Events
PSI OB Trauma
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pbrn.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/cg/child-eng-cg30-2353a.pdf
August 01, 2015 - months, did you contact this
provider’s office to get an appointment for
your child for an illness, injury
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pbrn.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023-NHQDR-appendixes-ACDE-rev.pdf
January 01, 2023 - 1,000 elective-surgery admissions, age
18 and over
HCUP 2020
Reclosure of postoperative abdominal wound … admissions of length 2 or more
days, age 18 and over
HCUP 2020
Home health care patients whose surgical wound … 2020
Home health care patients whose management of oral
medications improved
OASIS 2021
Birth trauma … 1,000 elective-surgery admissions, age
18 and over
HCUP 2020
Reclosure of postoperative abdominal wound … 2020
Home health care patients whose management of oral
medications improved
OASIS 2021
Birth trauma
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pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes8.html
August 01, 2022 - CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure Injury
-
pbrn.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/safe-electronic-slides.html
July 01, 2023 - Sentinel Event Alert: Issue #30 Preventing Infant Death and Injury During Delivery. 2004.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/healthited-issuebrief.pdf
February 01, 2021 - facilitate communication about diagnostic testing in adult
patients presenting to an ED with minor head injuries … Tablet-based patient-centered
decision support for minor head injury in the emergency department: pilot
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b3a_combo_chartsforpresentations.xlsx
January 01, 2006 - 0.1493487343 PSI 12 Statistically Lower 0
PSI 13 Postoperative sepsis 17.433 0
PSI 14 Postoperative wound … 0.0683602771 PSI 15 Statistically Lower 0
PSI 16 Transfusion reaction 0.000004 0
PSI 17 Birth trauma … - injury to neonate 2.188 0
PSI 18 Obstetric trauma - vaginal with instrument 0.139241 0.062898 … 0.215583 133.928 -99.8960329431 0.0570030165 0.0570022699 PSI 18 Statistically Lower 0
PSI 19 Obstetric trauma … 0.01989 -100 -100 117.3881347411 PDI 10 No Statistically Significant Difference 0
PDI 11 Postoperative Wound
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring.pptx
May 01, 2017 - Sentinel Event Alert: Issue #30 Preventing Infant Death and Injury During Delivery. 2004. http://www.jointcommission.org
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pbrn.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/ced-appendix2-comments.xlsx
October 12, 2022 - effective, limiting its review to whether the process is reasonable and necessary to treat or diagnose an injury … effective, limiting its review to whether the process is reasonable and necessary to treat or diagnose an injury