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psnet.ahrq.gov/perspective/are-we-getting-better-measuring-patient-safety
November 10, 2015 - national efforts to reduce medical errors and improve patient safety (i.e., "freedom from accidental injury
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psnet.ahrq.gov/web-mm/failure-rescue-mother
September 23, 2020 - Related Resources
WebM&M Cases
Uterine Artery Injury
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www.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html
June 01, 2022 - patients can suffer adverse outcomes and even fatal complications, and clinicians can be exposed to injury
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module3/module3-assessment-change-readiness-gap-analysis.pptx
August 25, 2015 - An adverse event is "any injury caused by medical care" and doesn't imply "error," "negligence," or poor
-
www.ahrq.gov/ncepcr/reports/2024-annual-report/recent-grants-systems.html
May 01, 2024 - Appendix D: Grant Summaries
P1: Does A New Care Model Improve Care for Patients with Acute Kidney Injury
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psnet.ahrq.gov/web-mm/risks-absent-interoperability-medication-induced-hemolysis-patient-known-allergy
April 08, 2019 - The Case A 47-year-old man with paraplegia (secondary to a gunshot wound) and a history of polysubstance … Unfortunately, his cardiac arrest led to an anoxic brain injury, and he remained in a vegetative state
-
www.ahrq.gov/sites/default/files/2025-03/smith-werner-carayon-report.pdf
January 01, 2025 - primary complaint of fall occurring within the previous 48 hours; were not categorized as a level 1 trauma … roles represent a range of
professional backgrounds, including medicine (e.g., ED attending physician, trauma … sufficient
info or explanation
(e.g., pain
management, finding
test results in pt
portal, impact of
injury … info
organized logically,
important info on
front page
• Useful info in AVS
(e.g., info on home
care (wound … Preventable medical injuries in older patients. Arch Intern Med.
2000;160:2717-2728.
14.
-
effectivehealthcare.ahrq.gov/sites/default/files/arthritis_hi_impact.pdf
January 01, 2014 - Increasing age, obesity, injury to or overuse of a
joint, and genetics can all contribute to the disease … therapy has been
used by high-profile athletes to speed their recovery process after soft tissue injuries … PRP has been used in a number of hemostatic applications as
well as for treatment of soft tissue injuries … such as tendonitis and chronic wounds.
48
Patient blood is
collected and centrifuged to concentrate … Arch Orthop
Trauma Surg 2011 Mar;131(3):311-7. PMID:
20714903
54.
-
psnet.ahrq.gov/web-mm/right-left-neither
November 16, 2022 - signed and faxed to the other hospital to obtain records of the recent ED visit for the ankle and foot injury
-
effectivehealthcare.ahrq.gov/sites/default/files/clifford.pdf
May 29, 2025 - So if we were to look for something like bursitis, which is a knee injury,
we have about 122 patients
-
psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
October 10, 2017 - 2
A 38-year-old male patient was hospitalized and treated with IV antibiotics for a traumatic injury
-
www.ahrq.gov/patient-safety/settings/hospital/candor/impguide.html
August 01, 2022 - Medicine (IOM) report, To Err Is Human: Building a Safer Health System , the problems associated with injury
-
psnet.ahrq.gov/node/33678/psn-pdf
January 01, 2009 - that one reason the
number is so low is that patients were unaware that a medical error caused their injury
-
psnet.ahrq.gov/node/49702/psn-pdf
March 01, 2014 - laboratory
data was notable for an elevated white blood cell (WBC) count of 23,000/mm3, acute kidney injury
-
psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
May 11, 2019 - He was diagnosed with a rotator cuff injury and underwent left shoulder surgery.
-
psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
May 29, 2024 - Laboratory tests showed acute kidney injury with markedly elevated levels of potassium, phosphate, and
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/001-ss-antimicrobial-prophylaxis-1-fg.docx
April 01, 2025 - Vancomycin is known to cause nephrotoxicity resulting in acute kidney injury (AKI).
-
digital.ahrq.gov/sites/default/files/docs/citation/r18hs026188-gong-final-report-2022.pdf
January 01, 2022 - frequent re-admissions, and high costs in the hospital.4 Because ARDS
develops after some initial injury … is a major contributor and driver to
the mortality reported by better recognized conditions such as trauma … hospital floor, ICU); 3) because ARDS develops acutely and co-exists with other serious
conditions like trauma … of mechanical ventilation,
Page 10 of 21
Phase 2 involved prevention of complications and lung injury … Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury
-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/2017qdr-patsafchartbook.pdf
October 01, 2018 - per 1,000 instrument-assisted deliveries
• Birth trauma - injury to neonate per 1,000 selected live … Adverse Drug Events
• An adverse drug event (ADE) is an injury—including physical harm, mental harm, … • Measures include:
Home health care patients whose surgical wounds improved or healed, 2010- … Improvement
Home health care patients whose surgical wounds improved or healed,
2010-2016
50
60 … The home health team should regularly change wound dressing and teach the patient about
wound care.
-
effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-213-lower-limb-protheses-evidence-summary.pdf
September 01, 2018 - Furthermore, the review excludes studies of exclusively
military amputees with battle-related trauma … 5 years after receipt
of an LLP, (accounting for intervening mortality,
subsequent surgeries, or injuries … be representative
of the Medicare population, being both mostly young and
with amputations due to trauma … Studies did not explicitly account
for intervening mortality or subsequent surgeries or
injuries. … prosthetic knees and were mostly
conducted in younger men with unilateral transfemoral
amputations due to trauma