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www.innovations.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/index.html
February 01, 2018 - Effectiveness Reviews
Facilities
Home and Community Resources
Findings Report
Injuries
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www.innovations.ahrq.gov/funding/training-grants/grants/active/kawards/kawdsumbrown.html
October 01, 2014 - Institution: Dartmouth College Grant Title: Patient Safety and Acute Kidney Injury Grant Number: K01 … Evaluate whether high-intensity quality improvement reduces the risk of contrast-induced acute kidney injury
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www.innovations.ahrq.gov/patient-safety/settings/hospital/index.html
March 01, 2024 - CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure Injury … Pressure Injury Prevention in Hospitals Training Program supports the training of hospital staff on … in-person training curriculum and a series of companion webinars on specific topics related to pressure injury
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www.innovations.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/index.html
May 01, 2016 - Effectiveness Reviews
Facilities
Home and Community Resources
Findings Report
Injuries
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www.innovations.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.innovations.ahrq.gov/sites/default/files/wysiwyg/patients-consumers/diagnosis-treatment/treatments/btpills/btpills.pdf
September 01, 2015 - You also need to avoid activities and sports that could cause injury. … the
bracelet lets health care workers know
that you are taking a blood thinner.
7
To prevent injury … To prevent injury outdoors:
■ Always wear shoes.
■ Wear gloves when using sharp tools.
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www.innovations.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.
Leadership.
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www.innovations.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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www.innovations.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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www.innovations.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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www.innovations.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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www.innovations.ahrq.gov/research/findings/studies/index.html?page=484
January 01, 2024 - Behavioral Health
(699)
Blood Clots
(62)
Blood Pressure
(132)
Blood Thinners
(79)
Brain Injury … (255)
Imaging
(245)
Implementation
(191)
Infectious Diseases
(260)
Influenza
(41)
Injuries … and Wounds
(207)
Inpatient Care
(221)
Intensive Care Unit (ICU)
(267)
Kidney Disease and … Tools & Toolkits
(49)
Training
(143)
Transitions of Care
(192)
Transplantation
(141)
Trauma … Adv Skin Wound Care 2013 Feb;26(2):83-92; quiz p.93-4. doi: 10.1097/01.ASW.0000426718.59326.bb.
.
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www.innovations.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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www.innovations.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-199-section-6-b-pmcoe-picu-expert-workgroup.pdf
September 18, 2014 - providers dedicated to skin care and HAPU prevention, e.g., an
institution-wide skin-care council led by wound … stakeholders including CCM, ENT, General Surgery, Plastic
Surgery, Dermatology, Transplant Surgery, Trauma … • Staging of Pressure ulcers would need to be done by a wound care expert vs. the PICU staff nurse … • Evaluation of potential pressure injury is labor intensive and subjective; data cannot be obtained … • Given the severity of illness/injury in PICU patients, 48 or 72 hours seems more reasonable to
-
www.innovations.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-200-section-6-b-expert-workgroup.pdf
September 18, 2014 - providers dedicated to skin care and HAPU prevention, e.g., an
institution-wide skin-care council led by wound … stakeholders including CCM, ENT, General Surgery, Plastic
Surgery, Dermatology, Transplant Surgery, Trauma … • Staging of Pressure ulcers would need to be done by a wound care expert vs. the PICU staff nurse … • Evaluation of potential pressure injury is labor intensive and subjective; data cannot be obtained … • Given the severity of illness/injury in PICU patients, 48 or 72 hours seems more reasonable to
-
www.innovations.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-203-section-6-b-workgroup.pdf
September 18, 2014 - providers dedicated to skin care and HAPU prevention, e.g., an
institution-wide skin-care council led by wound … stakeholders including CCM, ENT, General Surgery, Plastic
Surgery, Dermatology, Transplant Surgery, Trauma … • Staging of Pressure ulcers would need to be done by a wound care expert vs. the PICU staff nurse … • Evaluation of potential pressure injury is labor intensive and subjective; data cannot be obtained … • Given the severity of illness/injury in PICU patients, 48 or 72 hours seems more reasonable to
-
www.innovations.ahrq.gov/health-literacy/professional-training/lepguide/chapter1.html
September 01, 2020 - not be harmed by the care that is intended to help them, and they should remain free from accidental injury … Adverse event*:
Any injury caused by medical care. … include pneumothorax from central venous catheter placement, anaphylaxis to penicillin, postoperative wound … Similarly, postoperative wound infections count as adverse events even if the operation proceeded with … Near miss/close call * :
An event or situation that did not produce patient injury, but only because
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - o Decreased central nervous system input (head injury, ingestion of central nervous system
depressant … o Peripheral nerve/neuromuscular junction (spinal cord injury, organophosphate/carbamate
poisoning,
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/intramuscular-injections.pdf
June 01, 2021 - intramuscular (IM) administration is important to make
sure the vaccine does its job and to avoid shoulder injury … and Health Administration (OSHA) regulations
do not require you to wear gloves unless you have
open wounds
-
www.innovations.ahrq.gov/funding/training-grants/grants/active/kawards/kawards.html
July 01, 2019 - Primary Care
Brown, Jeremiah
K01 HS018443
Dartmouth College
Patient Safety and Acute Kidney Injury … K08 HS017960
University of Pennsylvania
The Comparative Effectiveness of Time-Adjusted Trauma Center … HS017952
Johns Hopkins University
Does Screening Variability Make DVT an Unreliable Quality Measure of Trauma … K08 HS021271
Yale University
Clinical Decision Support for Mild Traumatic Brain Injury
Miller,