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preventiveservices.ahrq.gov/news/newsroom/case-studies/201702.html
March 01, 2017 - Injuries from falls and immobility.
Obstetrical adverse events.
Pressure ulcers. … Improvements in 2014 resulted in an estimated 45 percent reduction in pressure ulcers, 24 percent reduction
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preventiveservices.ahrq.gov/patient-safety/settings/long-term-care/resource/index.html
November 01, 2021 - Effectiveness Reviews
Facilities
Home and Community Resources
Findings Report
Injuries … Nursing Homes: On-Time Prevention
End of Life Care
Home and Community-based Services
Falls and Injury … Long-Term Care Facilities
Multiple Chronic Conditions
Omissions of Care in Nursing Homes
Pressure
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preventiveservices.ahrq.gov/patient-safety/settings/long-term-care/index.html
September 01, 2021 - Effectiveness Reviews
Facilities
Home and Community Resources
Findings Report
Injuries … Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention is a team training curriculum to … help nursing homes with electronic medical records reduce the occurrence of pressure ulcers.
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_3-communication-speaker-notes.pdf
July 01, 2023 - patient's
family members.
4
Hospital AIM
Team
Leads
SPPC‐II
Maternal and Perinatal Deaths and Injuries … communication breakdowns are identified as the primary root
cause of maternal and perinatal deaths and injuries … Other root causes for maternal and perinatal deaths and injuries are—
• Assessment (i.e., the adequacy … Severe‐range blood
pressure was sustained for nearly an hour. Ms. … Untitled
Communication Severe Hypertension
Communication is…
Maternal and Perinatal Deaths and Injuries
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preventiveservices.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-1/guide.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 … 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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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module1/module1_tools.docx
March 01, 2013 - bodies have definitions (e.g., the NQF defines a fall as “an unplanned descent to the floor without injury … study by van Gaal and colleagues evaluated a program that targeted three patient safety practices (pressure … and found an overall positive effect on the development of any adverse event, a composite measure of pressure … out specific fall assessments or interventions, and investigations such as lying and standing blood pressure … Violence and Injury Prevention: Falls. 2012.
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preventiveservices.ahrq.gov/patient-safety/settings/hospital/fall-prevention/webinar/slides.html
June 01, 2018 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … Healthcare Research & Quality
Toolkit: https://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries … Slide 28
Challenge
Unable to sustain falls prevention
Graph with on falls and falls with injury … Falls and falls with injury decreased from 2008 to 2009 but increased in 2010 and 2011.
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preventiveservices.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
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preventiveservices.ahrq.gov/patient-safety/settings/hospital/fall-tips/index.html
February 01, 2021 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … Background
Falls are the most common cause of preventable injury.
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preventiveservices.ahrq.gov/data/infographics/index.html
March 01, 2024 - Antidepressant Prescriptions
Potentially Preventable Pediatric Hospital Stays
Most Common Cause of Injuries … 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 … Hemodialysis Patients Worse Among Blacks
HRSA's Health Center Program Making Progress on Blood Pressure
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-implementation-handouts.docx
July 01, 2016 - We record onset day, stage, and surface area of each pressure ulcer during wound rounds. … ulcer healing and you will be able to identify wounds suspected of infection. … Injury Alliance’s Prevention and Treatment of Pressure Ulcers Guidelines
c. … Wound, Ostomy, and Continence Nurses Society (WOCN) Pressure Ulcer Guidelines
d. … Ulcer Report
Pressure Ulcers At Risk for Delayed Healing
Weekly Wound Rounds Report
Weekly Pressure
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preventiveservices.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/practices.html
January 01, 2013 - Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … This assessment should include checking for a history of osteoporosis, including prior low-trauma fractures … Some may even sustain an injury. … In cases of falls with significant trauma, the patient may need to be taken to surgery. … Prevention of falls and fall injuries in the older adult.
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-implementation-handouts.pdf
July 01, 2016 - We record onset day,
stage, and surface area of each pressure ulcer during wound rounds. … ulcer healing and you
will be able to identify wounds suspected of infection. … Pressure Injury Alliance’s Prevention and Treatment of Pressure Ulcers
Guidelines
c. Wound, Ostomy … X X X X
Wound rounds Multidisciplinary team weekly review
of residents with pressure ulcers. … Rounds
Report and Pressure Ulcers at Risk for Delayed Healing with wound rounds.
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-erepguide.pdf
February 10, 2014 - Healing
Weekly Wound Rounds Report
Weekly Pressure Ulcer Treatment Summary Report
Pressure … home chains, and wound centers. … Injury Alliance. … The wound nurse, wound
physician, and other disciplines attending wound rounds can see
quickly which … Treatments
Wound Cleanser.
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/comments/prp-wound-care-comments.pdf
September 01, 2020 - For diabetic foot ulcers, this
involves restoring perfusion, offloading
pressure, wound debridement … For pressure ulcers,
management of pressure, friction, shear
and moisture in addition to good wound … We excluded wounds of other
etiologies, including traumatic wounds,
peripheral arterial disease (PAD … ) related
wounds in nondiabetics (i.e., diabetic
wounds are to be included regardless of
the presence … Our members
report that they also use PRP for athletic
overuse injuries.
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preventiveservices.ahrq.gov/hai/pfp/haccost2017.html
November 01, 2017 - Comparison to 2010 AHRQ estimates
Summary
Despite advancements in infection control and injury prevention … can stem from diagnostic or treatment errors (e.g., failure to follow antibiotic protocols); medical injuries … Beginning in 2008, CMS identified the HACs (e.g., CAUTI, falls and trauma, surgical site infection) for … Falls
Fall during an inpatient admission, with or without injury, whether or not fall was assisted. … Pressure Ulcers
A new pressure ulcer developed during a stay, or Stage 1 or 2 pressure ulcer(s) present
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preventiveservices.ahrq.gov/patient-safety/settings/hospital/candor/impguide/apc.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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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_3_communication.pptx
July 01, 2023 - interruption to a doctor who is with a patient's family members.
2
Maternal and Perinatal Deaths and Injuries … communication breakdowns are identified as the primary root cause of maternal and perinatal deaths and injuries … Other root causes for maternal and perinatal deaths and injuries are—
Assessment (i.e., the adequacy, … Smith so you can treat her severe blood pressure and draw labs. … Smith, you do not have severe-range blood pressure at this time.
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/hmv-protocol-appendixa.pdf
October 11, 2017 - or NPPV or "Positive Airway Pressure*" or "positive end-
expiratory pressure*").ti.
25411
3 1 or … 5811
14 *Obesity/ 256788
15 *Respiratory Insufficiency/ 25610
16 *Scoliosis/ 20526
17 *Spinal Cord Injuries … ventilation" or "non-invasive positive pressure ventilation" or NPPV or "Positive Airway
Pressure*" … ventilation" or "non-invasive positive pressure ventilation" or NPPV or "Positive Airway
Pressure*" … ventilation" or "non-invasive positive pressure
ventilation" or NPPV or "Positive Airway Pressure*"
-
preventiveservices.ahrq.gov/patient-safety/settings/hospital/resource/qitool/index.html
March 01, 2017 - Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … detailed information on best practices for selected indicators
Introduction PDF [248.26 KB] PSI03 Pressure … Pulmonary Embolism or DVT PDF [136.84 KB] PSI13 Postoperative Sepsis PDF [78.65 KB] PSI14 Postoperative Wound … Dehiscence PDF [137.17 KB] PSI15 Accidental Puncture or Laceration PDF [115.46 KB] PSI18-19 Obstetric Trauma … Respiratory Failure PDF [270.5 KB] PDI10 Postoperative Sepsis PDF [286.81 KB] PDI11 Postoperative Wound