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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/engagement.pptx
May 01, 2017 - Program for Perinatal Care
Patient & Family
16
Engaging After Adverse Events
An adverse event is an injury … to a patient caused by medical intervention rather than by the underlying disease or condition of the … Victim: Health Care Workers7
Health care workers involved in an adverse event experience their own trauma … Many hospitals have developed employee assistance programs and medically induced trauma support services … Medical error: the second victim. The doctor who makes the mistake needs help, too.
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www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/hisph-slides-pt2.html
May 01, 2018 - Slide 39
Maternity Care for Hispanics
Note:
Trends: Birth trauma and obstetric trauma were … Slide 43
Birth trauma—injury to neonate per 1,000 live births, by race/ethnicity, 2004-2012
Image … : Graph shows birth trauma—injury to neonate per 1,000 live births:
Year
Total
White
Black … Note:
Trends:
Birth trauma-neonatal injury rates fell from 2.6 per 1,000 live births in 2004 … Between 2004 and 2012, birth trauma-neonatal injury rates fell for all racial/ethnic groups.
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psnet.ahrq.gov/issue/technology-education-and-safety-0
December 02, 2020 - June 15, 2011
Preventing patient positioning injuries in the nonoperating room setting
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psnet.ahrq.gov/node/33729/psn-pdf
May 01, 2012 - errors contribute to 44,000–98,000 deaths, and more than a million
injuries, annually in United States … The incidence of adverse events and medical error in pediatrics. … Patient safety efforts should focus on medical injuries. JAMA.
2002;287:1993-1997. … Temporal trends in
rates of patient harm resulting from medical care. … Medical errors in the USA: human or systemic? Lancet. 2011;377:1289.
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psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
January 29, 2021 - and procalcitonin levels were elevated, serum creatinine was 1.5 mg/dL (consistent with acute kidney injury … direct injection into an artery by a nurse or a physician is fortunately far less common than this non-medical … when the patient is hypotensive. 7,8,9 Arterial injection of drugs can cause ischemia by direct vessel injury … Pa Patient Saf Advis. 2010;7(2):41-45. [ Free full text ] Examples of Medical Device Misconnections. … Injection injury of an aberrant superficial radial artery requiring surgical intervention.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apiiie.html
June 01, 2010 - Access
Populations: Children with developmental disabilities or delays who also have significant medical … 17
HCBS MS Domains: Timeliness
Populations: Adults with HIV/AIDS, Adults with acquired brain injuries … Illinois
Tool or Measure Set: Performance Measures for Illinois HCBS Waiver for Persons with Brain Injury … Need, Coordination of Long-Term Care and Other Services
Populations: Adults with acquired brain injuries … guardian of consumer
Mode of Data Collection: Telephone interview
Total Items/indicators: Home medical
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hcup-us.ahrq.gov/reports/factsandfigures/2007/exhibit5_10.jsp
January 01, 2007 - Pneumonia
281
249
31.8
33.3
-11
Respiratory failure
36
65
4.1
8.7
80
Injury … and poisoning
873
904‡
100.0
100.0
4
Complication of surgical procedures or medical
-
www.ahrq.gov/patients-consumers/prevention/disease/bloodclots.html
August 01, 2017 - Your Guide to Preventing and Treating Blood Clots
Blood clots are a serious medical … throm-BO-sis]) most often occur in people who can't move around well or who have had recent surgery or an injury
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psnet.ahrq.gov/issue/what-are-experiences-team-members-involved-root-cause-analysis-qualitative-study
August 16, 2023 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure injuries … quality improvement project to reduce risks of inadvertent insulin pen sharing at a large academic medical
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psnet.ahrq.gov/issue/patient-safety-resident-well-being-and-continuity-care-different-resident-duty-schedules
July 23, 2010 - September 3, 2014
The Accreditation Council for Graduate Medical Education resident duty … March 3, 2011
Extended work duration and the risk of self-reported percutaneous injuries
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psnet.ahrq.gov/issue/do-patient-safety-indicators-explain-increased-weekend-mortality
June 01, 2011 - June 1, 2011
A randomized trial of a multifactorial strategy to prevent serious fall injuries … Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical
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psnet.ahrq.gov/issue/structural-racism-60-year-old-black-woman-breast-cancer
December 17, 2020 - June 26, 2019
A randomized trial of a multifactorial strategy to prevent serious fall injuries … Topic
Hospitals
Facility and Group Administrators
Quality and Safety Professionals
Medical
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psnet.ahrq.gov/issue/harms-discharge-primary-care-mixed-methods-analysis-incident-reports
October 12, 2016 - May 18, 2022
Association of adverse effects of medical treatment with mortality in the … United States: a secondary analysis of the Global Burden of Diseases, Injuries, and Risk Factors study
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psnet.ahrq.gov/issue/quantification-hawthorne-effect-hand-hygiene-compliance-monitoring-using-electronic
July 29, 2020 - Same Author(s)
A randomized trial of a multifactorial strategy to prevent serious fall injuries … Physician burnout, well-being, and work unit safety grades in relationship to reported medical
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psnet.ahrq.gov/issue/use-beers-criteria-predict-adverse-drug-reactions-among-first-visit-elderly-outpatients
October 27, 2016 - January 21, 2015
System approach to prevent common bile duct injury and enhance performance
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psnet.ahrq.gov/issue/cdc-grand-rounds-preventing-unsafe-injection-practices-us-health-care-system
February 27, 2019 - October 31, 2014
Assessing the National Electronic Injury Surveillance System—Cooperative
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psnet.ahrq.gov/issue/drive-deprescribe
August 19, 2020 - March 24, 2021
Utilizing quality improvement methods to prevent falls and injury from
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.332_slideshow.ppt
September 01, 2014 - Herzig, MD, MPH, Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical … Co-morbidity and utilization of medical services by pain patients receiving opioid medications: data … and its relationship to the patient's chronic pain complaint is crucial
Is acute pain related to an injury … Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod3.html
March 01, 2019 - Knowing When a Fall Has Occurred
Risk Factors for Falls
Session 2
Limiting Falls that Cause Injury
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/suicidal-thoughts-young-people-draft-protocol.pdf
March 14, 2024 - characteristics,
comorbidities, social
determinants of health,
race/ethnicity, racism,
and history of trauma … or potential for injury)
o Those who have made suicide attempts in the
absence of known suicidal … 13 years, 14–17 years, and 18–24
years)
• Gender/gender identity
• Race/ethnicity
• History of trauma … Products Regulatory Agency, relevant conference
proceedings, patient advocate group websites, and medical … factors (e.g., demographic characteristics [e.g., age, race,
ethnicity, socioeconomic status]), patient medical