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www.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* [
-
www.ahrq.gov/research/findings/making-healthcare-safer/index.html
July 01, 2023 - , and obstetric adverse events are responsible for thousands of deaths and hundreds of thousands of injuries
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-November_45.pdf
January 01, 2007 - resident physicians were
asked to complete incident reporting cards identifying obstacles to care, injuries … The following definitions were
used to code the type of event:
• Adverse events were injuries that … • Potential adverse events were errors where injuries could have occurred but did not, either
due … Injury by type and severity
Injury and severity N %
Adverse events 7 9
Life Threatening 1 … Since near misses do
not result in injuries and are, therefore, unlikely to carry medical liability,
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/workplace-safety-resources.pdf
May 01, 2023 - Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention
Program
https://www.cdc.gov … lifting, repositioning, and transfers represent some of the most common—and most
preventable—sources of injury … This brief questionnaire can be used to examine the number and
nature of patient handling injuries in … www.ahrq.gov/teamstepps/webinars/previous-webinars-2016.html
Clinical teams can learn how to reduce risk of injury … Healthcare Outcomes
Well-Being Initiative
Workbook for Designing, Implementing, and Evaluating a Sharps Injury
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Vane.pdf
February 01, 2005 - Surgeries included multiple traumas and burns. … Patient Safety During Military Deployments
471
Combat missions involved trauma and burn surgeries … Humanitarian missions included
trauma surgery along with a broad-based OR capability, which included … When the fixed facility hospital in Baghdad was established and wounds were
cultured out, there was … a number of surgical site wound infections.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallspxspecs.pdf
February 01, 2018 - nursing positions, including managers,
supervisors, charge nurses, other staff nurses, MDS nurses, wound … and minor injuries and display
sum. … One fall may have major and minor injuries.
Display count as major injury, never both. … One fall may have multiple minor injuries,
but count as one. … One fall may have multiple major injuries,
but count as one.
9 Total
Residents
Who Fell
Compute
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/transform.pdf
January 01, 2020 - Patient falls, which are common in hospitals, can result in
serious injuries, extend a patient’s stay … By 2020 the estimated annual cost of fall injuries for older
people will exceed $30 billion.7,8 Now that … improving light sources for
surgical staff; and designing patient beds to reduce back stress,
fatigue, and injuries
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apiiif.html
June 01, 2010 - March 7 and March 21, 2008
Kentucky
Tool or Measure Set: Kentucky Acquired Brain Injury … Timeliness, Access, Health and Welfare, Quality of Life
Populations: Adults with acquired brain injuries … Developer: Division of Long Term Care and Community Alternatives, Brain Injury Services Branch … The brain injury waiver has used some type of evaluation or satisfaction survey since its inception. … physical and cognitive disabilities, adults with physical disabilities, adults with acquired brain injuries
-
www.ahrq.gov/sites/default/files/2024-10/landrigan3-report.pdf
January 01, 2024 - physician sleep deprivation can result in an increased risk
of medical errors and increased risk of injuries … to medical residents and others (e.g., car
accidents, needle stick injuries). … 24 hours of wakefulness, which has been associated with
increased medical errors and occupational injuries … >24 hours of wakefulness, which has been associated with
increased medical errors and occupational injuries
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/ltvv-litreview.docx
January 01, 2017 - trial with 20 patients without lung disease, requiring mechanical ventilation admitted to either a trauma … High tidal volume is associated with the development of acute lung injury after severe brain injury: … regression analysis adjusted for baseline characteristics and underlying ARDS risk factors (sepsis, trauma … Ventilator-associated lung injury in patients without acute lung injury at the onset of mechanical ventilation … , such as multiple transfusions, trauma, sepsis, or high-risk surgery.
-
www.ahrq.gov/sites/default/files/2024-02/mackenzie-report.pdf
January 01, 2024 - No operator injuries occurred with a redesigned
instrument tray. … Trauma Center. … The outcomes from
patients admitted, as measured by the Trauma and Injury Severity Score
(TRISS) methodology … The practices at STC for CTI may not
reflect other trauma centers practices, and the severity of injury … Of the 38 patients, 13 (34%) died within 24 hours due
to the severity of their injuries and not
-
www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2021.pdf
January 01, 2021 - pertaining to nine patient safety event
types that represent the majority of reported preventable injuries … Injuries were divided into three groups: No
Injury where the incident did not result in harm, Injury … that they represent minor injuries such as soreness, bumps, and minor
abrasions. … Injuries were divided into two groups: Fall considered unassisted and Fall
known to be assisted. … Injuries were stratified by twelve patient activities: Ambulating
with assistance and/or assistive device
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/ltvv-factsheet.docx
January 01, 2017 - Emerging evidence links protective tidal ventilation to decreased incidence of acute lung injury (ALI … not yet have ARDS and particularly those with risk factors to prevent progressive development of lung injury … with lower tidal volumes as compared with conventional tidal volumes for patients without acute lung injury … Ventilator-associated lung injury in patients without acute lung injury at the onset of mechanical ventilation … What tidal volumes should be used in patients without acute lung injury?
-
www.ahrq.gov/patient-safety/settings/hospital/resource/safety-assess.html
October 01, 2020 - The toolkit:
Targets six areas of safety—infections, falls, medication errors, security, injuries
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mvp/ltvv-intro/ltvv-intro-slides.pptx
January 01, 2017 - Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury … Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury … Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury … Emerging Evidence5
Multi-hit theory
Priming: initial insult → at risk for ARDS
Pneumonia
Sepsis
Trauma … inhalation
Pulmonary contusion
Pulmonary vasculitis
Sepsis
Systemic inflammatory response syndrome
Trauma
-
www.ahrq.gov/hai/pfp/haccost2017-appendix.html
November 01, 2017 - , Closed"[Mesh] OR "Craniocerebral Trauma"[Mesh] OR "Cerebrovascular Trauma"[Mesh] OR "Cerebrovascular … Ostomy/wound Mgmt . 2016 Nov;62(11):30.
d Weiser TG, Semel ME, Simon AE, et al. … Ostomy Wound Manage . 2016 Nov;62(11):30-8.
Boltz MM, Hollenbeak CS, Julian KG, et al. … Cost of a ventilator-associated pneumonia in a shock trauma intensive care unit. … The cost of serious fall-related injuries at three Midwestern hospitals.
-
www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/part2-mch.html
May 01, 2018 - births
Same
No Change
Maternal deaths per 100,000 live births
Same
Narrowing
Birth trauma—injury … Groups With Disparities:
Hispanics had lower rates of birth trauma and obstetric trauma than Whites … Birth Trauma
Birth trauma—injury to neonate per 1,000 live births, by race/ethnicity, 2004-2012 … Trends:
Birth trauma-neonatal injury rates fell from 2.6 per 1,000 live births in 2004 to 1.9 per … Between 2004 and 2012, birth trauma-neonatal injury rates fell for all racial/ethnic groups.
-
www.ahrq.gov/hai/cauti-tools/archived-webinars/ed-catheter-insertions-slides.html
December 01, 2017 - Keeps patients from having to get up to urinate, protecting them from injury. … Trauma)
Admitting service (e.g. … Is immobilization needed for trauma or surgery? … Is the patient incontinent with open sacral or perineal wounds? … Protocolized care for trauma
Incontinence without open sacral or perineal wounds
Pre-operative
-
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/healthit-ed-4.html
February 01, 2021 - facilitate communication about diagnostic testing in adult patients presenting to an ED with minor head injuries
-
www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK2_T1-Medical_Care_Referral_Form_Word_doc_for_html_only.doc
June 02, 2025 - Suspected minor injury
Yes No ?
Suspected serious injury
Yes No ? … New or increasing pus draining from wound
Y
N
?
New breakdown
Y
N
? … New or expanding redness around wound
Y
N
?
Pain / tenderness
Y
N
?
Warmth
Y
N
?