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www.ahrq.gov/patient-safety/settings/hospital/resource/about.html
December 01, 2017 - Process
Millions of patients visit hospital emergency departments (EDs) each year for a variety of injuries … Pressure Injury Prevention in Hospitals Training Program
AHRQ developed the Pressure Injury Prevention … how to overcome the challenges associated with developing, implementing, and sustaining a pressure injury
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www.ahrq.gov/sites/default/files/2025-02/nance-report.pdf
January 01, 2025 - to
patients (when such injuries involve medical mistakes); and (4) identification of needed model … the
causation chain and then alter the system with the stated purpose of never allowing a similar
injury … Disclosure was also defined as a process of defusing the situation of a medical error
resulting in injury … Principal Investigator John Nance, p. 7
However, when addressing an injury (in the absence of some … subject was as follows:
“You can postulate a right of a patient to receive prompt notice of medical injury
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www.ahrq.gov/news/newsroom/case-studies/cquips1301.html
November 01, 2012 - Safety Culture" in 2006, when concern about the hospital's patient safety arose as a result of worker injuries … using the survey, the facility has shown a significant decrease in both the incidence of reportable injuries … Hospital Survey on Patient Safety Culture" at Newman Memorial Hospital, only one incident of a reportable injury
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www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
November 01, 2021 - • Patient safety concerns such as falls,
pressure injuries, and adverse medication
events were reported … Pressure Injury
Among the pressure injury events (n = 10; 3.3%), several records identified the development … of pressure
injuries due to the interaction between patient pronation and poor patient mobility. … Four records identified
the development of multiple pressure injuries to the lips, tongue, ears, and … The remaining pressure injuries were identified across multiple other contact points such as
the coccyx
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapc.html
December 01, 2017 - She was assessed to have no injuries resulting from the fall. … Physical restraint—increases risk of serious injury. … Full side rails—increase risk of serious injury. … P has no evidence of injury resulting from her two falls on 4/1/04 at this time. … P has no evidence of injury resulting from her two falls on 4/1/04 at this time.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
January 01, 2014 - Video: Do Less Harm
2
Presentation Goals
Highlight the gap between optimal response to medical injury … Resolution) process and how this toolkit will help organizations improve their response to medical injury … Module 1
Today’s presentation goals are to:
Highlight the gap between optimal response to medical injury … field of ergonomics; as we work more at desks and computers, these areas are redesigned to help prevent injuries … helps them care for their patients.
36
Module 1
In addition to the organization Medically Induced Trauma
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Gershon_88.pdf
January 01, 2012 - Although
24 percent of participants reported
that they provided wound care, only
a small proportion … 85.2)
Record vital signs 1,138 (79.2)
Provide urinary
catheter/ostomy care 556 (44.8)
Provide wound … The perception of risk of personal injury was high. … Childhood injury prevention at home and
play. Curr Opin Pediatr 1999; 11: 578-582.
6. … Iowa City: University of Iowa, Iowa Injury
Prevention Research Center; 2001.
52 .
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Tuinen.pdf
March 01, 2004 - Uses
have included characterizing the anatomical location of injury,1 injury severity,2, 3
disease … Classifying trauma severity based on hospital
discharge diagnoses. … J Trauma 1996;41(3):380–8.
4. Rutledge R, Osler T, Kromhout-Schiro S. … J Trauma 1998;45(4):791–9.
13. Hartz AJ, Kuhn EM. … Patient safety
efforts should focus on medical injuries. JAMA
2002;287(15):1993–7.
23.
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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-0206-technicalspecs.pdf
May 01, 2016 - Exclusions
• Denominator/Numerator Exclusions
o Trauma-related headache or pain (Table … IMG3) on the day of or within 7 days prior to
imaging
o Head trauma or suspected abuse/neglect (Table … 339.43
Other complicated 339.44
OTHER
Post-
traumatic
headache
339.2x
Acute pain
due to
trauma … excision of foreign body from brain 61570
Craniectomy or craniotomy; with treatment of penetrating wound … 852.x
Other/unspecified intracranial hemorrhage following injury 853.x
Intracranial injury of other
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kline_32.pdf
March 03, 2008 - , RN;
Patricia Brosnan, MPH, RN; Mary Dowling, MSN, RN
Abstract
Falls are a leading cause of injuries … Injuries sustained as result
of patient falls in a cancer hospital are often severe, due to the nature … deaths in adults aged 65 years and older.1, 2 Injuries sustained as result of patient falls in a
cancer … improvement falls prevention project with two goals:
decreasing patient falls and decreasing fall-related injuries … They
immediately realized that if
they wanted a realistic
chance of reducing falls and
injuries associated
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Masheter.pdf
March 01, 2004 - Detection of Inpatient Health Care Associated Injuries: Comparing Two ICD-9-CM Code Classifications … specific
kinds of AEs: new acute pulmonary embolism, acute myocardial infarction, and
postoperative wound … poisoning
(E-codes) in three categories: three obstetric or birth trauma indicators, eight
medical … Of particular
interest is obstetric (OB) vaginal trauma with instrument (26.517 percent for
UTIDs versus … highest values for both samples (11.132 percent for UTIDs versus 17.424 percent
for NIS), and OB vaginal trauma
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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/prevhosp/prevehosp-reports-ig.pdf
November 30, 2013 - Major injury
Minor injury
Non-Fall-Related Injury
Major injury
Minor injury
Musculoskeletal … o Rash
Fall-Related Injury:. … , an “X” will display in this column:
o Major injury
o Minor injury
Non-Fall-Related Injury. … Asthma
Circulatory problems
Hypertension
Gastroenteritis
Angina pectoris
Fall/trauma … cellulitis, dehydration, COPD, asthma, circulatory
problems, hypertension, gastroenteritis, angina,
falls/trauma
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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/ontime/fallspx/reports.html
November 01, 2017 - 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 … that causes pain
Injury Site
Head
Upper extremity (UE)
Lower … Whether injury resulted from the fall and, if so, the type and severity of the injury.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-indications.pptx
April 01, 2022 - Knight is a 25-year-old man who was admitted with acute urinary retention, due to spinal injury. … when no or little urine is seen in bladder
Consider urology consultation for prostatitis and urethral trauma … Closed pressure ulcers: stage I, deep tissue injury No No, unless has chronic ISC needs Yes, if the patient … require an indwelling urinary catheter if the wound can be kept clean by other methods
Use alternatives … J Wound Ostomy Continence Nurs. 2020;47(6):601-18. PMID: 33201147.
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report.pdf
January 01, 2022 - For 2022, the three highest individual AE rates are Advancing
Pressure Injuries or Complications of … of pressure injuries POA was significantly higher for males than
females (7.2% vs. 4.9%). … seizures,
coma)
Death during or shortly after anesthesia in ASA Class 1
patient
Dehiscence, flap or wound … or cranial nerve or spinal cord;
Malignant hyperthermia
Ocular injury
Peri-operative injury
Post-dural … Birth – Neonatal Other birth injury
3.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/slides.html
December 01, 2017 - Physical Restraints
Physical restraints increase the likelihood of serious injury resulting from … Consequences of Falls
Serious injury such as hip fracture
Increased risk of death associated