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pcmh.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-3/guide.html
September 01, 2017 - Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … Post-Fall Huddles: Reducing Preventable Falls and Fall-Related Injuries —AHRQ Fall Prevention Program … The patient should be carefully and systematically assessed for injuries. … The post-fall clinical review focuses on immediate risk of injury or complications. … RCA is often used for a fall with injury.
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pcmh.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-1/slides.html
September 01, 2017 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … Medicare won’t pay for increased costs due to injury from inpatient falls. … Falls harm patients.
30% to 51% of falls result in injury.
Many falls are preventable.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/pfphac.pdf
September 01, 2014 - With Central Venous Catheters
Falls MPSMS In-Hospital Patient Falls
Obstetric Adverse Events PSI OB Trauma … Pressure Ulcers
Surgical Site Infections NHSN SSIs combined for 17 procedures based on CDC NHSN data … The national number of adverse events captured by PSIs 18 and 19 on obstetric injury, and the
national … Ulcers
Hospital-Acquired Pressure
Ulcers
53.03 62.45 0.85
VAP Ventilator-Associated
Pneumonia … Falls MPSMS In-Hospital Patient Falls 262,317 32,750,000 8.010
Obstetric
Adverse Events
PSI OB Trauma
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a2_combo_boardpresentation.pdf
October 01, 2015 - October 2015:
– Addition of information relevant to ambulatory and managed
care encounters
– Expanded injury … • 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). … 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?
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pcmh.ahrq.gov/news/newsletters/e-newsletter/870.html
June 01, 2023 - for an estimated 4 million patients who might benefit from “ABCS” interventions ( a spirin, b lood pressure … Walsh has identified factors that contribute to medication errors and injuries in children with chronic … Trauma Case Rep . 2023 Apr;44:100800. Epub 2022 Feb 18.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/natlhacratereport-rebaselining2014-2016_0.pdf
January 01, 2016 - patient safety events, including
many types of hospital-acquired infections, adverse drug events, and injuries … Ulcers/Pressure Injuries
Surgical Site Infections
Ventilator-Associated
Pneumonias
(Post-op) Venous … Central Venous Catheters
Falls MPSMS In-Hospital Patient Falls
Obstetric
Adverse
Events
PSI OB Trauma … National number of adverse events captured by PSIs 18 and 19 on obstetric
injury and national number … 8,513 0.29
Falls MPSMS In-Hospital Patient Falls 238,965 8.03
Obstetric
Adverse
Events
PSI OB Trauma
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pcmh.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module5.pptx
January 01, 1995 - or unfolding error
An opportunity to interrupt or correct an action or event before there is harm or injury … It allows for one to take steps to interrupt or correct an action or event before there is harm or injury … Are the blood pressure cuffs, otoscope, and ophthalmoscopes working properly? … Are things being left undone because of time pressure?
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pcmh.ahrq.gov/sites/default/files/wysiwyg/teamstepps/diagnosis-improvement/module5-situation-monitoring.pptx
January 10, 2022 - It also ensures staff are supported in times of stress or production pressures or when the day is just … allows individuals and teams to take steps to interrupt or correct an action or event before harm or injury … risk or unfolding error
An opportunity to interrupt or correct an action or event before harm or injury … Are the blood pressure cuffs, otoscope, ophthalmoscopes, and other equipment working properly? … Are things being left undone because of time pressure?
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module1/module1_fall-prevention.docx
March 01, 2013 - In one study, a fall with serious injury added 6.3 days to the hospital stay. … The average operational cost for a fall with injury is about $14,000. … Between 30 and 51 percent of falls in hospitals result in an injury ranging from bruises to severe wounds … The cost of serious fall-related injuries at three Midwestern hospitals. … Thus, the CAUTI, SSI, and Pressure Injury committees used the AHRQ assessment tools, and a speak-up campaign
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
April 01, 2016 - Say:
Today’s Presentation Goals are to:
■ Highlight the gap between optimal response to medical injury … the CANDOR process and how this toolkit will help organizations
improve their response to medical injury … nursing
staff in the room had Michelle connected to a monitor and monitored her heart
rate, blood pressure … of ergonomics; as we work more at desks and computers, these areas
are redesigned to help prevent injuries … Slide 35
Say:
In addition to the organization Medically Induced Trauma Support Services (or
MITSS)
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pcmh.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3.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
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pcmh.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/notes.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 … An adverse event is "any injury caused by medical care" and doesn't imply "error," "negligence," or poor
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/CombatCare.pdf
March 18, 2014 - The right leg is continuing to bleed and now has pressure dressings
applied. … They seem overwhelmed by the extent of the patient’s injuries. … Seeing the blood pressure, the nurse asks, “Do you want a code cart in here?” … has an actively
hemorrhaging 6-inch laceration on his right lower leg but no other obvious signs of injury … While the physician
is reviewing wound care instructions with the mother, the child complains of nausea
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pcmh.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 … The nursing staff in the room had Michelle connected to a monitor and monitored her heart rate, blood pressure … 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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pcmh.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/healthyliving/qdr2015-chartbook-healthyliving.pdf
January 01, 2020 - , and
■ Birth trauma not elsewhere classified.24
Many of these injuries to neonates may be preventable … .25
Birth trauma—injury to neonate per 1,000 live births, 2004-2013
0.0
0.5
1.0
1.5
2.0
2.5 … Birth trauma—injury to neonate per 1,000 live births, 2004-2013
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5 … Trends:
■ Birth trauma-neonatal injury rates fell from 2.6 per 1,000 live births in 2004 to … Birth Trauma Rate—Injury to Neonate: Technical Specifications.
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pcmh.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes1.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
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pcmh.ahrq.gov/research/findings/studies/index.html
January 01, 2024 - Autism
(31)
Back Health and Pain
(58)
Behavioral Health
(699)
Blood Clots
(62)
Blood Pressure … (132)
Blood Thinners
(79)
Brain Injury
(64)
Breast Feeding
(18)
Burnout
(64)
Cancer … (255)
Imaging
(245)
Implementation
(191)
Infectious Diseases
(260)
Influenza
(41)
Injuries … and Wounds
(207)
Inpatient Care
(221)
Intensive Care Unit (ICU)
(267)
Kidney Disease and … Tools & Toolkits
(49)
Training
(143)
Transitions of Care
(192)
Transplantation
(141)
Trauma
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pcmh.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide6.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 … For additional support in the planning process, Medically Induced Trauma Support Services (MITSS) resources
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pcmh.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-4/slides.html
September 01, 2017 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI
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pcmh.ahrq.gov/news/newsletters/e-newsletter/861.html
April 01, 2023 - The COVID-19 pandemic has intensified these pressures. … J Trauma Acute Care Surg 2023 Apr;94(5):592-8. Epub 2023 Nov 18. … Renal outcomes following intravenous contrast administration in patients with acute kidney injury: a