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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/putoolkit_module5_tools.docx
June 02, 2025 - stakeholders and staff
Root cause analysis is conducted for each fall with at least moderate level of injury
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/webinars/webinar4_pu_skinassesst_final.pdf
April 01, 2011 - Management and
Advances in Skin and Wound Care
• Legal consultant and former NPUAP
board member … or coolness can indicate skin
damage, including—
– Stage I pressure ulcer
– Suspected deep tissue injury … venous or arterial)
– Neuropathic/diabetic
– Skin tears (especially forearm of older adults)
– Trauma … pressure ulcers he/she has
• Highest stage of his/her deepest ulcer
• Treatment for any existing wounds … Wound care essentials: practice principles. 3rd ed.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kleinpeter.pdf
January 01, 2004 - outcomes, we can measure both medical injury and medical
errors. … problem after harm or injury has occurred. … By focusing on injury prevention, the performance improvement team
methodology was successfully used … the ambulatory arena until we reach the goal of elimination of near
misses, medical errors, medical injuries … Patient safety
efforts should focus on medical injury. JAMA 2002
Apr 17;287(15):1993–7.
7.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab14b.html
February 01, 2023 - Assessing the Health and Welfare of the HCBS Population
Table 14B: Outcome Indicators by State Supply of Health Care Providers
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Table of Contents
Assessing the Health and Welfare of the HCBS Population
Introduction
HCBS Population
Availability and Use of State Medicaid H…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab16b.html
February 01, 2023 - Assessing the Health and Welfare of the HCBS Population
Table 16B: Outcome Indicators by State Socioeconomic Status
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Table of Contents
Assessing the Health and Welfare of the HCBS Population
Introduction
HCBS Population
Availability and Use of State Medicaid HCBS
Outco…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab15b.html
February 01, 2023 - Assessing the Health and Welfare of the HCBS Population
Table 15B: Outcome Indicators by State Demographics
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Table of Contents
Assessing the Health and Welfare of the HCBS Population
Introduction
HCBS Population
Availability and Use of State Medicaid HCBS
Outcome Indic…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apiiie.html
June 01, 2010 - 17
HCBS MS Domains: Timeliness
Populations: Adults with HIV/AIDS, Adults with acquired brain injuries … Illinois
Tool or Measure Set: Performance Measures for Illinois HCBS Waiver for Persons with Brain Injury … Need, Coordination of Long-Term Care and Other Services
Populations: Adults with acquired brain injuries … mental health disabilities, adults with severe and persistent mental illness, adults with acquired brain injuries
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/rep3.html
June 01, 2010 - settings, the primary goal of HCBS programs is not just to restore functional ability compromised through injury … health care services, but also the avoidance of serious adverse or preventable health outcomes, such as injury
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www.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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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flink.pdf
April 09, 2004 - concluding that mandatory and voluntary
systems can work together to help reduce death and serious injury … Health Law 2805-l12 requires
hospitals to report and investigate incidents of deaths and other serious injuries … • IV-related
• Embolic and related
disorders
• Laparoscopic
complications
• Perioperative injuries … Elopement from hospital leading to death/serious injury 923 44 0.6
Equipment malfunction leading … to death/serious injury 938 22 0.3
Infant abduction 961 8 0.1
Infant discharged to wrong family
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www.ahrq.gov/ncepcr/reports/2024-annual-report/recent-grants-health-equity.html
May 01, 2024 - Appendix D: Grant Summaries
P1: Does A New Care Model Improve Care for Patients with Acute Kidney Injury … The leading cause of death in 2020 in the US was heart disease, cancer, COVID-19, and unintentional injuries … The most common unintentional injury was drug overdose, accidental falls, and motor vehicle accidents
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www.ahrq.gov/nursing-home/resources/osha-covid-19-standards.html
May 01, 2022 - requirements in states that operate their own OSHA-approved State Plans; recordkeeping requirements and injury
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/research-centers/sheridan_screening_overuse.pdf
January 01, 2014 - such as physical, emotional/psychological, and costs:
Physical Emotional/Psychological Costs
Injury … from screening
or follow-up testing
Injury from potentially
unnecessary treatment
Stress
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmodap3a.html
October 01, 2014 - Nursing staff must have the knowledge and skills to prevent injury from falls.
-
www.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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www.ahrq.gov/hai/cauti-tools/phys-championsgd/section3.html
October 01, 2015 - Teamwork and Communication Definitions and Tools
Several examples of severe patient injury … The virulent organism caused a severe infection and irreversible injury to the patient.
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www.ahrq.gov/cahps/surveys-guidance/hcbs/index.html
January 01, 2025 - physical disabilities, people with developmental or intellectual disabilities, people with acquired brain injury
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-ostomy.pdf
June 02, 2025 - anchoring elements to bond the epidermis to the
underlying dermis, so skin is more susceptible to friction injury … ■ Peristomal skin must be protected from mechanical trauma due to use of aggressive adhesives,
improper
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/perinatal/chipra-0083-fullreport.pdf
March 01, 2016 - degree that it creates an unnecessary surgical incision as compared to less
severe posterior perineal trauma … study found that
women with midline episiotomy had a significantly greater rate of anal sphincter injuries … preponderance of the studies, however, supported a conclusion that
10
degree of perineal trauma … typically used in this literature are needed to
understand properly the relationships between perineal trauma … episiotomy compared with restrictive use was associated with higher risk of anal
sphincter and rectal injuries
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0083episiotomy.pdf
March 01, 2016 - degree that it creates an unnecessary surgical incision as compared to less
severe posterior perineal trauma … study found that
women with midline episiotomy had a significantly greater rate of anal sphincter injuries … preponderance of the studies, however, supported a conclusion that
10
degree of perineal trauma … typically used in this literature are needed to
understand properly the relationships between perineal trauma … episiotomy compared with restrictive use was associated with higher risk of anal
sphincter and rectal injuries