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www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/public-action-alliance-slides-040323_LOCKED.pdf
May 25, 2023 - factors focus
areas
• 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. … as
surge … our new normal
*Healthcare Acquired Infections, Early Elective
Deliveries, Falls with Injury … , Healthcare Acquired
Pressure Injuries, NTSV C-Section patients to get
to WHO Goal, Sepsis Mortality
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www.ahrq.gov/healthsystemsresearch/hspc-research-study/index.html
July 01, 2021 - areas of focus, such as research organized around specific diseases, body systems, populations, or injuries
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab15.html
February 01, 2023 - Assessing the Health and Welfare of the HCBS Population
Table 15A: Outcome Indicators by County Demographics
Previous Page Next Page
Table of Contents
Assessing the Health and Welfare of the HCBS Population
Introduction
HCBS Population
Availability and Use of State Medicaid HCBS
Outcome Indi…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/quarterlysum.html
November 01, 2017 - Sample Quarterly Summary of Falls Risk Factors by Unit (continued)
Injury
Totals
… Fall
With
Major
Injury
Fall
With
Minor
Injury
Total Residents
Who Fell
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/faclevel.html
November 01, 2017 - Sample Quarterly Summary of Falls Risk Factors by Facility (continued)
Injury
Totals …
Fall
With
Major
Injury
Fall
With
Minor
Injury
Total
Residents
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-195-section-2.pdf
January 01, 2016 - post-traumatic headache who were
evaluated in the emergency department (ED) within 24 hours after an injury … seizure or convulsions associated with trauma
History of loss of consciousness associated with trauma … Documentation of trauma
☐Yes ☐No
2b. … Date and time of trauma
___/___/_____ ___:___
3a. … Mark “Yes” for mechanisms of injury such as penetrating trauma, fall from more than 5 feet, pedestrian
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apiiid.html
June 01, 2010 - A few are related to the health and welfare of clients, such as injuries and medication errors. … HCBS MS Domains: Unmet Need
Populations: Individuals with disabilities, adults with acquired brain injuries … information concerning the number of incidents (abuse and neglect; restraints, crimes against, serious injuries … required data via NCI form titled "NCI Protocol for Reporting Incidents: Abuse and Neglect, Serious 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/vol2/Advances-Pichert_51.pdf
March 22, 2008 - After all,
given the large numbers of iatrogenic injuries worldwide,13, 14, 15, 16 error-affected patients … unsafe practices,32 recent reports suggest that a majority of claims do
appear to involve patient injuries … bottom line is that many, perhaps most, malpractice claims are reasonably related to medical
management injuries … Factors
that prompted families to file medical malpractice
claims following perinatal injuries.
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/implement-fac-guide.html
July 01, 2023 - Slide 6: Root Causes of Maternal and Perinatal Deaths and Injuries 2004-2012
Say:
Human factors … communication breakdowns are identified as the primary root cause of maternal and perinatal deaths and injuries … Other root causes for maternal and perinatal deaths and injuries are—
Assessment.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Keyes.pdf
January 01, 2004 - Identify the causes of preventable health care errors and patient injury
in health care delivery. … noted in the IOM report, approximately 3 to 4 percent of hospitalized
patients suffer preventable injuries … PSI) suggests that more than 32,000 deaths
annually may be attributable to the 18 types of medical injuries … sufficient to gain a complete
understanding of medical errors contributing to actual or potential
patient injury … Excess length of stay, charges, and
mortality attributable to medical injuries during
hospitalization
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module7/module7-resolution-facilitator.pptx
August 24, 2015 - Assess possible future injuries.
Assess lost income potential, loss of quality of life. … Potential future injuries that may result from the adverse event.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab4.html
March 01, 2023 - Enrollment
HCBS Subpopulations
Aged and Disabled
Aged Only
Physically
Disabled Only
Brain Injuries
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www.ahrq.gov/patient-safety/settings/multiple/index.html
August 01, 2023 - approaches to desgin tat target six areas of safety: infections, falls, medication errors, security, injuries
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www.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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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxoverviewmaterialspacket.pdf
June 02, 2025 - Conditions High-Risk Change in Condition
New Contributing
Risk Factor Additional Info Within 30 Days Injury … Yes/no N N Y Y Y N
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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www.ahrq.gov/sites/default/files/2024-01/scott-report.pdf
January 01, 2024 - Use the ambulatory surgical setting as a model to better understand risks and injuries and to focus … University of Michigan, complications may occur in
nearly 13% of cases.4 Preventable healthcare-related injuries … Excess length of stay, charges, and mortality attributable to medical injuries during
hospitalization … and implement team training curricula regarding
other domains, such as rare event crises in the OR, trauma
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/mcc/mccchartbook.pdf
April 01, 2014 - -4 NO YES
861 HEART & LUNG INJURY -5 NO -4 NO
863 GI TRACT INJURY -4 NO -3 NO
864 LIVER INJURY - … 3 NO -3 NO
869 INTERNAL INJURY NOS -3 NO -3 NO
871 EYEBALL OPEN WOUND -3 NO -4 NO
872 OPEN WOUND OF … OPEN WOUND OF LOWER ARM -5 NO -5 NO
882 OPEN WOUND OF HAND -5 NO -5 NO
883 OPEN WOUND OF FINGER -5 … 893 OPEN WOUND OF TOE -5 NO -5 NO
904 BLOOD VESSEL INJURY NEC -5 NO -4 NO
908 LATE EFF INJURY NEC … TO NERVE NEC/NOS -4 NO -4 NO
958 EARLY COMPLIC OF TRAUMA -4 NO -3 NO
959 INJURY NEC/NOS -4 NO -3 NO
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flack.pdf
January 01, 2005 - 519, mandates
that all manufacturers of medical devices must report device-related deaths,
serious injuries … facilities” must report medical device
related deaths to FDA and to the manufacturer and report serious injuries … of medical devices so it
could become more proactive in addressing device issues before a death or injury … the various types and sizes of facilities that are obligated to make
reports of deaths and serious injuries … facilities, it promotes a
blame-free environment in order to encourage the reporting of deaths, serious
injuries
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www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/taba.4.1.html
December 01, 2017 - Hepatic Infarction
Neuropathy
Polyneuropathy
Mononeuropathy, Other Neurological Conditions/Injuries
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www.ahrq.gov/sites/default/files/2024-10/gorelick-report.pdf
January 01, 2024 - The
majority of these are intended for use in trauma patients, including the Injury Severity Score, … Trauma Score, and Pediatric Trauma Score. 35 Others are available for asthma,36 croup,37 and
febrile … intravenous fluids
• oxygen
• prescription medications administered in ED (oral, IV, or inhaled)
• wound … The Injury Severity Score: a method for describing patinets with
multiple injuries and evaluating … The Injury Severity Score is unable to differentiate between poor care and severe injury.