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  1. www.cpsi.ahrq.gov/patient-safety/settings/hospital/resource/index.html
    August 01, 2022 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … Patients with Limited English Proficiency NICU Toolkit Preventing Falls in Hospitals Preventing Pressure
  2. www.cpsi.ahrq.gov/hai/pfp/hacrate2013-appendix.html
    October 01, 2015 - (2013) OB Trauma in Vaginal Delivery With (PSI18) and Without Instrument (PSI19) 77,000 2.4 Pressure … Ulcers MPSMS (2013) Hospital-Acquired Pressure Ulcers 1,060,000 32.5 Surgical Site Infections … $144,680,000 1' 100 Obstetric Adverse Events 82,000 77,000 5,000 6% $15,000,000 7 Pressure … 12.5% 25,000 $7,234 Obstetric Adverse Events 380,000 30% 50% 15% 57,000 $3,000 Pressure … been wrongly based on the full cost of a hospital stay that included a fall or a hospital-acquired pressure
  3. www.cpsi.ahrq.gov/patient-safety/settings/hospital/resource/qitool/webinar080116/index.html
    December 01, 2017 - Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … The number of hospitalizations involving pressure ulcers increased by about 80% between 1993 and 2006 … patients may have pressure ulcers at any one time. … Include in the medical record complete documentation of any pressure ulcer found. … Pressure Ulcer Risk Assessment at Admission and Daily: Evaluate all patients for pressure ulcers and
  4. www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a2_combo_boardpresentation.pdf
    October 01, 2015 - • Several exclusions (e.g., length of stay <5 days, principal diagnosis of pressure ulcer). … • Several exclusions (e.g., length of stay <5 days, principal diagnosis of pressure ulcer). … An Example: Pressure Ulcer (PDI 02) http://www.qualityindicators.ahrq.gov/Downloads/Modules/PDI/V45/ … A PSI Example: Pressure Ulcer (PSI 03)� What are the Inpatient Quality Indicators (IQIs)? … An Example: Pressure Ulcer (PDI 02)� How can the AHRQ QIs be used in quality assessment?
  5. www.cpsi.ahrq.gov/sites/default/files/wysiwyg/evidencenow/cooperatives/evidencenow-executive-summary-midwest.pdf
    November 01, 2017 - patients adopt the ABCS of cardiovascular disease prevention: Aspirin in high-risk individuals, Blood pressure … ethnically and socioeconomically) faces many cardiac health challenges: 31.2 percent have high blood pressure … prescription and cholesterol management; education and patient self-management tools to improve blood pressure … • Crash Course: Diving Deep into MIPS [2017] • Implementing a Practice-Led Self-Measured Blood Pressure … Monitoring Program [2017] • Improving Health Outcomes: Blood Pressure Measurement [2017] • Improving
  6. www.cpsi.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/intervention-tracking-notes-sw.pdf
    July 19, 2018 - follow up; PDSA on data accuracy of aspirin therapy; established a standardized clinic-wide blood pressure … on this topic Started work on this topic and achieved aim/goal Aspirin therapy Blood Pressure … management: Started work on this topic but stopped before reaching aimgoalBlood Pressure management … : Started and continue to work on this topicBlood Pressure management: Started work on this topic … and achieved aimgoalBlood Pressure management: Did not formally work on thisCholesterol management
  7. www.cpsi.ahrq.gov/sites/default/files/publications/files/interimhacrate2014_2.pdf
    November 19, 2015 - About 40 percent of this reduction is from adverse drug events, about 28 percent from pressure ulcers … Most of the deaths averted occurred as a result of reductions in the rates of pressure ulcers and adverse … Urinary Tract Infections Central Line-Associated Bloodstream Infections Falls Obstetric Adverse Events Pressure … 2013) OB Trauma in Vaginal Delivery W ith (PSI 18) and Without Instrument (PSI 19) 77,000 2.4 Pressure … Ulcers MPSMS (2014) Hospital-Acquired Pressure Ulcers 1,010,000 30.9 7 2010 baseline data
  8. www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b3a_combo_chartsforpresentations.xlsx
    January 01, 2006 - Death in low-mortality DRGs 0 0 0.000717 0.265 -100 0 0.2705660377 PSI 02 Statistically Lower 0 PSI 03 Pressure … 0.00057 -47.8771929825 -100 88.5614035088 PDI 01 No Statistically Significant Difference 0 PDI 02 Pressure … Remove the "Pressure Ulcers" part of the title and revise it to reflect your PSI or IQI of interest … Remove the "Pressure Ulcers" part of the title and revise it to reflect your PSI or IQI of interest … Remove the "Pressure Ulcers" part of the title and revise it to reflect your PSI or IQI of interest
  9. www.cpsi.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/hmv-protocol.pdf
    February 02, 2018 - addition, some patients with chronic respiratory failure may benefit from continuous positive airway pressure … Areas of device variability include: mode of ventilation (such as pressure targeted ventilation versus … targeted ventilation using a mask interface, the FDA has approved HMVs which can provide pressure targeted … ventilation supplied by a Home Mechanical Ventilator (HMV), Bilevel Positive Airway Pressure device … (BPAP), and Continuous Positive Airway Pressure device (CPAP) in the home through a noninvasive interface
  10. www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hacreport-2019.pdf
    January 01, 2019 - ulcers/pressure injuries and falls. … For example, measured adverse drug events continued to drop from 2014 to 2017, while measured pressure … ulcers/pressure injuries increased from 2014 to 2015 and then decreased somewhat from 2015 to 2016 … Ulcers/ Pressure Injuries 21.7 23.5 22.7 23.0 6% 17.4 Surgical Site Infections 2.5 2.5 2.5 … Ulcer MPSMS Hospital-Acquired Pressure Ulcers/Pressure Injuries Surgical Site Infection NHSN SSIs
  11. www.cpsi.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/slides.html
    December 01, 2017 - Use Low Blood Pressure Precautions Slide 1. … Paralysis, tremors Loss of joint mobility, contractures Lower extremity weakness Drop in blood pressure … Provide safe shoes and slippers Promote safety during transfer and bathroom use Use low blood pressure … - Provide safe shoes and slippers - Promote safety during transfer and bathroom use - Use low blood pressure … Use Low Blood Pressure Precautions For residents with low blood pressure: Sit on edge of bed
  12. www.cpsi.ahrq.gov/sites/default/files/wysiwyg/evidencenow/about/evidencenow-factsheet.pdf
    April 01, 2021 - This included the “ABCS” of heart health: Aspirin use by high-risk individuals, Blood pressure control … Such pressures worsen a fundamental problem: it takes many years for new evidence to make its way into … aspirin for eligible patients n A 6.3% increase in cholesterol management n A 2.8% increase in blood pressure … control – an important finding, given decreasing national rates of blood pressure control.
  13. www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-nephro.pdf
    December 13, 2013 - ■ Blood pressure: Not higher in infants with nephrocalcinosis, but overall higher in preterm infants … ■ Should have: – Blood pressure checked at every visit.
  14. www.cpsi.ahrq.gov/evidencenow/projects/heart-health/about/stories/achievements.html
    March 01, 2021 - Health Center Holly Clinic (Holy, CO)   Helping primary care practices use evidence to improve blood pressure … selected Million Hearts® Hypertension Control Champions have worked with their patients to achieve blood pressure
  15. www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.xlsx
    July 01, 2016 - Value-based purchasing • Sentinel event • Publicly reported • Public perception • Marketing • Competitive pressure … Patient Safety PSI 03 Pressure Ulcer   PSI 06 Iatrogenic Pneumothorax PSI 07 Central Venous Catheter-Related … Neonatal Blood Stream Infection Rate Pediatric PDI 01 Accidental Puncture or Laceration Rate PDI 02 Pressure
  16. www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014FinalHACreport4Web-13Dec2016.pdf
    December 01, 2016 - About 40 percent of the overall reduction is from adverse drug events, about 28 percent from pressure … Tract Infections Central Line-Associated Bloodstream Infections Falls Obstetric Adverse Events Pressure … Most of the deaths averted occurred as a result of reductions in the rates of pressure ulcers and adverse … 2014) OB Trauma in Vaginal Delivery With (PSI 18) and Without Instrument (PSI 19) 74,000 2.3 Pressure … Ulcers MPSMS (2014) Hospital-Acquired Pressure Ulcers 1,010,000 30.9 Surgical Site Infections
  17. www.cpsi.ahrq.gov/patient-safety/settings/hospital/match/table-6.html
    August 01, 2012 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … ordered for patient instead of extended-release E Error that could have caused temporary harm Blood pressure
  18. www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.pdf
    June 29, 2016 - purchasing • Sentinel event • Publicly reported • Public perception • Marketing • Competitive pressure … PSI 03 Pressure Ulcer 1.2 1.3 7 $109,870 $ 769,087 N 6 7 7 Y Y Y Y Y PSI 06 Iatrogenic … purchasing • Sentinel event • Publicly reported • Public perception • Marketing • Competitive pressure … purchasing • Sentinel event • Publicly reported • Public perception • Marketing • Competitive pressure … Y N PDI 01 Accidental Puncture 0.3 0.6 1 $41,204 $ 41,204 N 9 9 9 Y Y Y Y Y PDI 02 Pressure
  19. www.cpsi.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/exh7-4.html
    October 01, 2014 - Blood Pressure (AQA and HEDIS Measure) Percentage of members with diabetes with most recent blood pressure … √ √ 12 mos Seeing a change in clinical outcomes, such as blood pressure, might take a year …   √ 12 mos   Blood Pressure Percentage of members with congestive heart failure (CHF) … with most recent blood pressure <140/80 mm Hg Claims. … √ √ 12 mos Seeing a change in clinical outcomes, such as blood pressure, might take a year
  20. Clabsitoolsap5 (doc file)

    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/clabsitools/clabsitoolsap5.doc
    December 11, 2012 - lumen (to avoid air embolism and ensure intravascular placement) Transduce central venous pressure … or estimate central venous pressure by fluid column (to avoid arterial placement) After the

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