-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Fein.pdf
January 01, 2004 - Costs
of medical injuries in Utah and Colorado. Inquiry
1999;36:255–64.
4. Barach P, Small SD. … Patients’ and
doctors’ attitudes to amount of information given after
unintended injury during treatment
-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/carbapenem-resistant-1.pdf
March 01, 2020 - , making
environmental contamination a concern for patients who are incontinent, who have draining wounds … in the incidence
of carbapenem-resistant Enterobacteriaceae (CRE)
colonization in the Severe Brain Injury … transmission, including one study in
an ICU7 and one hospital-wide study that included a severe brain-injury … intervention,
1,084 long-term
acute care
facility (LTACF)
patients;
included a 25-
bed severe
brain injury … intervention
was associated with
a decline in the
incidence of CRE
colonization in the
severe brain injury
-
integrationacademy.ahrq.gov/products/topic-briefs/polysubstance-use
February 01, 2025 - the effects of one substance by taking another Prevent withdrawal symptoms Cope with daily effects of trauma … potentially fatal ones Depressants with Depressants (e.g. opioids and benzodiazepines) Accidents or injury … That said, the use of Buprenorphine and benzodiazepines increases the risk for death and accidental injury … problems, including genetics, epigenetics, brain region involvement, environmental influences, stress, trauma … National Center for Injury Prevention and Control, Division of Drug Overdose Prevention.
-
cdsic.ahrq.gov/sites/default/files/2023-09/FINAL%20OO%20PC%20CDS%20SDM%20Report.pdf
January 01, 2023 - , app,
portal]
Approach to
Personalization Source
Concussion or
Brain Bleed
Minor head injury … Screening Emergency room
patients with minor
head injury
App Assesses risk and makes
a recommendation … Usability Evaluation of
Integrated Clinical Decision Support With
a Patient Decision Aid for Minor Head
Injury … Evaluation of a Patient-Centered Fall-Prevention Tool Kit to Reduce Falls and Injuries:
A Nonrandomized
-
psnet.ahrq.gov/web-mm/turn-other-cheek
October 26, 2010 - reported sentinel events , unexpected occurrences involving death or serious physical or psychological injury
-
hcup-us.ahrq.gov/nrdoverview.jsp
July 01, 2025 - Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis, procedure, and external cause of injury
-
psnet.ahrq.gov/web-mm/bowel-prep
March 01, 2017 - August 8, 2019
WebM&M Cases
Missing the Point—Eye Injury
-
psnet.ahrq.gov/perspective/unintended-consequences-florida-medical-liability-legislation
February 01, 2003 - conferences, root cause analyses, and any other professional exchange of information related to a patient's injury
-
psnet.ahrq.gov/web-mm/refused-medication-error
November 01, 2005 - Initial therapy was to carefully correct his acute renal injury while using lactulose to improve his
-
psnet.ahrq.gov/node/33884/psn-pdf
July 01, 2019 - Calibration drift in regression and machine
learning models for acute kidney injury.
-
psnet.ahrq.gov/node/49823/psn-pdf
March 01, 2018 - also known to easily cross the placenta and ingestions of large doses may also lead to
fetal liver injury
-
psnet.ahrq.gov/node/49646/psn-pdf
February 01, 2012 - department (ED) and was admitted to the hospital
for delirium, an underlying infection, and acute kidney injury
-
psnet.ahrq.gov/web-mm/not-all-headaches-are-due-migraine-red-flags-dont-miss-diagnoses-and-diagnostic-pitfalls
February 17, 2021 - Approximately five years after the first hospitalization, the patient suffered a head injury at work.
-
psnet.ahrq.gov/web-mm/untimely-end-despite-end-life-care-planning
February 01, 2012 - patient displayed worsening neurological status and a CT scan revealed diffuse brain edema and anoxic injury
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/guides/ena-slides.pdf
September 01, 2015 - Need for resources
• What teams need to be activated (specialists, code team, trauma team, brain injury … lumbar spine,
unstable pelvic fracture)
appropriate
Promote healing of open sacral or perineal
wounds … • The patient who requires immobilization for trauma or surgery
Inquire about the length of the … • The patient who is incontinent with open sacral or perineal wounds
Consult with the wound care
-
www.ahrq.gov/sites/default/files/publications/files/ena-slides.pdf
September 01, 2015 - Need for resources
• What teams need to be activated (specialists, code team, trauma team, brain injury … lumbar spine,
unstable pelvic fracture)
appropriate
Promote healing of open sacral or perineal
wounds … • The patient who requires immobilization for trauma or surgery
Inquire about the length of the … • The patient who is incontinent with open sacral or perineal wounds
Consult with the wound care
-
psnet.ahrq.gov/web-mm/one-dose-two-errors
September 29, 2017 - consulting nephrologist felt that amphotericin toxicity was the most likely cause of the acute kidney injury … September 29, 2017
WebM&M Cases
Missing Trauma
May
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod2sess1.html
October 01, 2014 - Residents are most safe—protected from harm or injury—when it is normal and accepted that care providers
-
www.ahrq.gov/hai/tools/mvp/modules/vae/surveillance-fac-guide.html
February 01, 2017 - For acute lung injury—was a low tidal volume ventilation protocol used for the patient?
-
psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
April 01, 2006 - July 10, 2019
Classifying errors in preventable and potentially preventable trauma deaths … WebM&M Cases
Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury