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www.ahrq.gov/hai/pfp/hacrate2013-refs.html
October 01, 2015 - Injury From Falls
Barrett JA, Bradshaw M, Hutchinson K, et al. … Fall and injury prevention (Chapter 10). In: Hughes RG, ed. … Preventing falls and eliminating injury at Ascension Health. … The road to zero preventable birth injuries. Jt Comm J Qual Patient Saf 2008;34:201-5. … Eliminating birth trauma at Ascencion Health. Jt Comm J Qual Patient Saf 2007;33:15-24.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/research-centers/sheridan_screening_overuse.pdf
January 01, 2014 - such as physical, emotional/psychological, and costs:
Physical Emotional/Psychological Costs
Injury … from screening
or follow-up testing
Injury from potentially
unnecessary treatment
Stress
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www.ahrq.gov/cahps/surveys-guidance/item-sets/pcmh/measures.html
May 01, 2017 - Respondent and provider talked about injury prevention
PCMH8.
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www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter1.html
August 01, 2022 - Reviewers
List of Tables and Exhibits
Evidence documenting health care-associated injury
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www.ahrq.gov/sites/default/files/wysiwyg/data/SyH-DR-PUF-Summary-Statistics-Medicare-Outpatient-Weighted.pdf
September 26, 2023 - clinical and laboratory findings, not elsewhere classified 15,581,930 9.05 150,440,673 87.34
S00-T88: Injury … clinical and laboratory findings, not elsewhere classified 9,411,866 5.46 157,550,833 91.46
S00-T88: Injury … clinical and laboratory findings, not elsewhere
classified
97,148 0.06 171,199,544 99.39
S00-T88: Injury … clinical and laboratory findings, not elsewhere
classified
76,614 0.04 171,426,766 99.52
S00-T88: Injury … clinical and laboratory findings, not elsewhere
classified
57,049 0.03 171,628,254 99.64
S00-T88: Injury
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www.ahrq.gov/data/infographics/index.html
July 01, 2025 - Antidepressant Prescriptions Potentially Preventable Pediatric Hospital Stays Most Common Cause of Injuries … 2017 People Who Spent the Most for Healthcare in 2017 Causes of Hospital Stays for Traumatic Brain Injury … in 2017 High Healthcare Spending in 2017 Sports-Related Traumatic Brain Injuries Among Children Inpatient
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www.ahrq.gov/patient-safety/reports/advancing-patient-safety.html
March 01, 2024 - Liability (PSML) Initiative to address four goals: (1) putting patient safety first by reducing preventable injuries … better communication between doctors and patients, (3) ensuring fair and timely compensation for medical injuries
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www.ahrq.gov/news/newsroom/case-studies/201804.html
July 01, 2018 - Falls by 21 Percent
Search All Impact Case Studies
July 2018
Patient falls resulting in injury
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a1b_combo_psifactsheet.pdf
October 01, 2015 - Thrombosis Rate
4.99 0450 2012
PSI 13 Postoperative Sepsis Rate 9.61
PSI 14 Postoperative Wound … Laceration Rate X 1.89 0345 2012
PSI 16 Transfusion Reaction Count X N/A* 0349 2012
PSI 17 Birth Trauma … Rate – Injury to Neonate 1.89
PSI 18 Obstetric Trauma Rate – vaginal delivery
with instrument … 133.19
PSI 19 Obstetric Trauma Rate – vaginal delivery
without instrument
20.97
PSI 90
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www.ahrq.gov/patient-safety/about/uni-chicago-medicine.html
February 01, 2024 - distribution to a system-wide weekly nursing newsletter, the message to prevent VTE and reduce hospital injuries … Collaboration across trauma, orthopedics, neurology, and neurosurgery led to optimization of anticoagulation … practices in the trauma patient population, which was implemented through a standardized protocol. … practices in the trauma patient population, which was implemented through a standardized protocol. … distribution to a system-wide weekly nursing newsletter, the message to prevent VTE and reduce hospital injuries
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man2.html
December 01, 2017 - the nurse after a resident falls should include a review of the resident systems and description of injuries … The presence or absence of a resultant injury is not a factor in the definition of a fall. … A fall without injury is still a fall.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb24.html
December 01, 2017 - Program (FMP) is directed at identifying and managing residents at high risk for falls and related injuries
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www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK2_T4-Common_Suspected_Infections_Tools_to_Improve_Communication_and_Decision_Making.ppt
May 01, 2014 - In wound infections among soldiers in the Middle East, multidrug resistant acinetobacter infections have … problem
Vital signs
Usual cognitive function
Recent/current health status (including falls)
Falls, minor injury … : require on-site first aid treatment (dressing, ice pack, pain medication)
Falls, serious injury: require … does not have COPD
- suspected or proven influenza in the absence of a secondary infection
- a skin wound … mobility (passive or active)
Acetaminophen 650 mg as needed or prior to cleaning/dressing changes
Cleanse wounds
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/004-ss-antimicrobial-prophylaxis-part-2.pptx
April 01, 2025 - Evaluation of intra-operative topical vancomycin and the incidence of acute kidney injury. … 202221
Double-masked, placebo-controlled RCT
Cardiac surgery, >100 patients
No difference in sternal wound … Topical vancomycin and risk of sternal wound infections: a double-blind randomized controlled trial. … Evaluation of intra-operative topical vancomycin and the incidence of acute kidney injury. … Topical vancomycin and risk of sternal wound infections: a double-blind randomized controlled trial.
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/one-pager-clostridioides-difficile.pdf
June 01, 2021 - Severe CDI: WBC ≥15,000 cells/mL OR acute increase in serum creatinine to ≥1.5 mg/dL OR
acute kidney injury … Assessment of kidney injury as a
severity criteria for Clostridioides difficile
infection.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapa.html
December 01, 2017 - Review article: Physical restraint removal, falls and injuries. … Centers for Disease Control (CDC) National Center for Injury Prevention and Control (NCIPC). … Fall and injury prevention in older people living in residential care facilities.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereports.html
September 01, 2017 - Weekly wound review meeting
* MDS=Minimum Data Set. … and skin, injury (fall related or not fall related), musculoskeletal, abnormal labs or anemia, fever … or skin issues
Fall-related injury
Non-fall-related injury
Abnormal labs
Fever/possible infection … disease
Asthma
Circulatory problems
Hypertension
Gastroenteritis
Angina pectoris
Falls/trauma … obstructive pulmonary disease, asthma, circulatory problems, hypertension, gastroenteritis, angina, falls/trauma
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kleinpeter.pdf
January 01, 2004 - outcomes, we can measure both medical injury and medical
errors. … problem after harm or injury has occurred. … By focusing on injury prevention, the performance improvement team
methodology was successfully used … the ambulatory arena until we reach the goal of elimination of near
misses, medical errors, medical injuries … Patient safety
efforts should focus on medical injury. JAMA 2002
Apr 17;287(15):1993–7.
7.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Rojas.pdf
March 15, 2004 - These elements were wound
dehiscence requiring repair, displacement/migration/ breakage of implant, … thrombosis requiring repair, postoperative wound infection, wrong patient/site,
incorrect procedure … Adverse events have
been defined as “an injury that was caused by medical management (rather than
the … Excess length of stay, charges and
mortality attributable to medical injuries during
hospitalization … Looking for medical injuries
where the light is bright. JAMA 2003;290(14):1917–9.
22.
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www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/intro.html
August 01, 2022 - dispute resolution, with the joint aims of (1) putting patient safety first by reducing preventable injuries … better communication between doctors and patients, (3) ensuring fair and timely compensation for medical injuries