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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/062-protocol-training-decolonization-with-chg.pptx
October 01, 2024 - Superficial pressure injuries (stages 1 and 2)
CHG should also be applied over sutured or stapled wounds … Clean wound carefully with CHG. … Apply CHG with firm pressure, unless the wound is over a bony prominence. … Using the CHG on superficial wounds, and stage 1 and 2 pressure injuries. … Refer to the slides on Wound Care.
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www.ahrq.gov/sites/default/files/2025-03/mcfarland-report.pdf
January 01, 2025 - Institute of Medicine (2000) estimated that, in 1999, as many as
98,000 people may have died owing to injuries … Seriousness of harm varied from a minor temporary injury or near miss to an injury that
would permanently … permanent injury. … Minor Permanent Error: A permanent injury that does not compromise basic functions of daily living. … Minor Temporary Error: Minor patient injury, increased patient monitoring, or change in treatment plan
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/ed-catheter-insertions-091013.ppt
January 01, 2010 - Facilitates I/O measurement
Keeps patients from having to get up to urinate, protecting them from injury … Incontinent with open sacral/perineal wounds
Consult with wound care
End of life/hospice
Be sure it … Trauma)
Admitting service (e.g. … Incontinent with open sacral/perineal wounds?
End of life/hospice? … Protocolized care for trauma
Incontinence without open sacral or perineal wounds
Pre-operative
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-rural-healthcare2.html
October 01, 2024 - 21 At the patient level, it is estimated that 33 percent of diagnostic errors result in patient injury … Rural residents are more susceptible to unintentional injury, as many work in high-risk occupations (
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod3sess3.html
October 01, 2014 - Safety means avoiding, preventing, and lessening the effects of harm and injury while residents are in … According to the National Center for Injury Prevention and Control, "fall prevention takes a combination … To prevent injury from falls, all nursing staff need knowledge and skills. … Nursing staff must have the knowledge and skills to prevent injury from falls. … Injury Prevention and Control: Home and Recreational Safety; Falls in Nursing Homes.
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report-nov-rev.pdf
January 01, 2022 - or complications of pressure injuries present on admission (POA)
was significantly higher (8.4% vs. … 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/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report-oct-rev.pdf
January 01, 2022 - or complications of pressure injuries present on admission (POA)
was significantly higher (8.4% vs. … 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/research/findings/final-reports/environmental-scan-programs/envscan-program1.html
April 01, 2018 - Safety
Definition of Patient Safety
Reference
Freedom from accidental or preventable injuries … glossary.aspx )
The prevention of health care errors and elimination or mitigation of patient injury … National Patient Safety Foundation
Freedom from accidental injury; ensuring patient safety involves … The avoidance, prevention, and amelioration of adverse outcomes or injuries stemming from the processes … final definition below:
Patient safety is the prevention and amelioration of adverse outcomes or injuries
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www.ahrq.gov/patient-safety/quality-measures/qsrs/index.html
July 01, 2025 - population at risk numbered at least 100, the highest rates for both 2021 and 2022 were worsening pressure injuries … Pressure Injury. Surgery/Anesthesia. Venous Thromboembolism. Other. … determined that national efforts to reduce hospital-acquired conditions such as adverse drug events and injuries
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b4_combo_documentationcoding.pdf
March 15, 2016 - PSI 18,
PSI 19
OB Trauma – Vaginal Delivery
With Instrument
OB Trauma – Vaginal Delivery
Without … X
PDI 11 Postoperative Wound
Dehiscence Rate
X Depth of the wound dehiscence:
external/superficial … injury or caused by medical
intervention (iatrogenic). … X
PSI 14 Postoperative Wound
Dehiscence
X Depth of the wound dehiscence:
external/superficial vs … PSI 18
PSI 19
OB Trauma – Vaginal
Delivery With Instrument
OB Trauma – Vaginal
Delivery Without
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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-2/vol1/Advances-November_45.pdf
January 01, 2007 - resident physicians were
asked to complete incident reporting cards identifying obstacles to care, injuries … The following definitions were
used to code the type of event:
• Adverse events were injuries that … • Potential adverse events were errors where injuries could have occurred but did not, either
due … Injury by type and severity
Injury and severity N %
Adverse events 7 9
Life Threatening 1 … Since near misses do
not result in injuries and are, therefore, unlikely to carry medical liability,
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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
-
www.ahrq.gov/sites/default/files/wysiwyg/data/SyH-DR-PUF-Summary-Statistics-Medicare-Inpatient-Weighted.pdf
September 26, 2023 - 58.96
2: Urgent 2,410,468 16.26 11,150,440 75.22
3: Elective 3,444,403 23.24 14,594,843 98.45
5: Trauma … clinical and laboratory findings, not elsewhere classified 593,149 4.00 13,129,037 88.57
S00-T88: Injury … clinical and laboratory findings, not elsewhere classified 593,149 4.00 13,129,037 88.57
S00-T88: Injury … clinical and laboratory findings, not elsewhere classified 642,003 4.33 13,909,750 93.83
S00-T88: Injury … clinical and laboratory findings, not elsewhere classified 768,214 5.18 13,760,139 92.82
S00-T88: Injury
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www.ahrq.gov/teamstepps-program/curriculum/situation/tools/monitoring.html
June 01, 2023 - It allows individuals and teams to take steps to correct the issue before harm or injury to the patient
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallspxselfassessment.pdf
June 02, 2025 - taking measures to prevent further falls in those who have had a
previous fall/falls (with or without injury …
If the activity was unusual for the resident
Interviews with witnesses
Body check for injury … Initiative for Nursing Facilities,
http://www.ahrq.gov/professionals/systems/long-term-
care/resources/injuries … www.fallpreventiontaskforce.org/
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries … /fallspx/fallspxmanual.pdf
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries
-
www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2020.pdf
January 01, 2020 - pertaining to nine patient safety event
types that represent the majority of reported preventable injuries … captures the specific type of physical
injury sustained in the fall as TYPE OF INJURY AS RESULT OF … The second most frequent type of injury reported was Other injury, representing 39.7% (3,268 /
8,229 … that they represent minor injuries such as soreness, bumps, and
minor abrasions. … and the type of the injury.
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www.ahrq.gov/topics/childrenadolescents.html
January 01, 2011 - Home
University of Iowa Uses AHRQ Data to Study Ways to Lower Incidence, Costs of Sports-Related Injuries
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www.ahrq.gov/research/findings/evidence-based-reports/techbrief16.html
July 01, 2014 - (ACP) honors patients’ goals and preferences for future care by creating a plan for when illness or injury
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Davis_60.pdf
April 07, 2008 - failure modes and effects analysis (FMEA) is a widely used technique for assessing
risk of patient injury … Introduction
Catastrophic patient injury often occurs because of an unanticipated sequence of active … becoming widespread and has been developed for
numerous applications.9, 10, 11 Catastrophic patient injury … ) to “major
injury” to “death.” … Preventing infant death and injury during delivery.
Sentinel Event Alert.