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preventiveservices.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool-30day.html
March 01, 2013 - 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/patient-safety/resources/resources/patient-safety-tools-flyer-June2022.pdf
May 01, 2023 - approaches to design that target six areas of safety:
infections, falls, medication errors, security, injuries … Web: ahrq.gov/vtguide
Preventing Pressure Ulcers: A
Toolkit for Improving Quality of Care in Hospitals … Web: ahrq.gov/pressureulcertoolkit
■ Pressure Injury Prevention in Hospitals Training
Progam supports … the training of hospital staff on
how to implement AHRQ’s Preventing Pressure
Ulcers in Hospitals … injury prevention.
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/mcc/mccchartbook.pdf
April 01, 2014 - -4 NO YES
861 HEART & LUNG INJURY -5 NO -4 NO
863 GI TRACT INJURY -4 NO -3 NO
864 LIVER INJURY - … 3 NO -3 NO
869 INTERNAL INJURY NOS -3 NO -3 NO
871 EYEBALL OPEN WOUND -3 NO -4 NO
872 OPEN WOUND OF … OPEN WOUND OF LOWER ARM -5 NO -5 NO
882 OPEN WOUND OF HAND -5 NO -5 NO
883 OPEN WOUND OF FINGER -5 … 893 OPEN WOUND OF TOE -5 NO -5 NO
904 BLOOD VESSEL INJURY NEC -5 NO -4 NO
908 LATE EFF INJURY NEC … TO NERVE NEC/NOS -4 NO -4 NO
958 EARLY COMPLIC OF TRAUMA -4 NO -3 NO
959 INJURY NEC/NOS -4 NO -3 NO
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preventiveservices.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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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module2/module2_slides_fallprev.pptx
August 24, 2017 - Process
Change process strategies can be applied to other quality improvement efforts:
Hospital-acquired pressure … injuries
Catheter-associated urinary tract infections
Deep vein thrombosis or pulmonary embolism following
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_3-communication-speaker-notes.pdf
July 01, 2023 - 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 … Her blood pressures have
remained normotensive, and she has had good
reflexes throughout the shift. … Her
blood pressures have remained normotensive, and she has had good reflexes throughout
the shift. … 2023
Communication Obstetric Hemorrhage
Communication is…
Maternal and Perinatal Deaths and Injuries
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preventiveservices.ahrq.gov/teamstepps/instructor/scenarios/combatcare.html
March 01, 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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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/obesity_topic-refinement.pdf
May 22, 2014 - Adverse effects of interventions
● Activity-related injury
● Adverse effects of medication ( diarrhea … Respiratory disease (i.e., asthma, COPD)
● Sleep apnea
o BMI
o Adverse effects
● Activity-related injuries … Question
1b
CMS Intermediate
outcomes
We are excluding all intermediate
outcomes (adherence, blood pressure … outcomes
CMS Intermediate
outcomes
We are excluding all intermediate
outcomes (adherence, blood pressure … skinfold thickness and waist
circumference; excluding all intermediate outcomes (adherence, blood pressure
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2023.pdf
January 01, 2023 - An
example of additional detail from the Fall module would be the type of injury sustained in a
fall … Pressure Ulcers result in harm to the patient
by their very nature. … This is unexpected, as pressure ulcers result in harm
to the patient by their very nature. … unstageable
• A lesion that, on admission, was a suspected Deep Tissue Injury
• A pressure ulcer … Pressure Ulcers result in harm to the patient by their very nature.
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/2-preventablehospitalandedvisits-samplerpts_3.pdf
November 30, 2013 - • Current clinical conditions contributing to transfer risk: use of oxygen, catheter or
ostomy, any pressure … 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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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2022qdr-final-es.pdf
October 01, 2022 - injury deaths),
followed by accidental falls and motor vehicle accidents (each of which accounted for … approximately 20% of unintentional injuries) … an important cause of death that
disproportionately affects younger populations, was unintentional injury … • Among the top 10 causes of YPLL, rates of unintentional injury, heart disease, liver disease,
and … eclampsia/preeclampsia rate, which measures a complication of pregnancy
characterized by high blood pressure
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preventiveservices.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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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-based-reports/services/quality/patientsftyupdate/ptsafetysum.pdf
March 01, 2013 - “common;” examples include falls,
venous thromboembolism (VTE), potential adverse drug
events, or pressure … The scope must also consider the severity of each event;
for instance, most falls do not result in injury … patient safety target, such as adverse drug events, or
general clinical topics, such as preventing pressure … High
(hypoglycemia)
Low-to-
moderate
NA
Interventions to prevent contrast-induced
acute kidney injury … Common/
Moderate
High Moderate
(bleeding)
Low Little/Moderate
Preventing patient death or serious injury
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preventiveservices.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-2/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 … applied to other quality improvement efforts in a hospital, such as preventing:
Hospital-acquired pressure … injuries.
-
preventiveservices.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_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, … Her blood pressures have remained normotensive, and she has had good reflexes throughout the shift. … Her blood pressures have remained normotensive, and she has had good reflexes throughout the shift.”
-
preventiveservices.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
-
preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module3/module3_fall-prevention.docx
January 01, 2013 - Prevention Program Training Webinar
Post-Fall Huddles: Reducing Preventable Falls and Fall-Related Injuries … medications or medicines that could cause sedation, confusion, impaired balance, or orthostatic blood pressure … 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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preventiveservices.ahrq.gov/patient-safety/settings/hospital/red/toolkit/ptoutcome-mail.html
March 01, 2013 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI
-
preventiveservices.ahrq.gov/patient-safety/settings/hospital/candor/impguide.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 … Medicine (IOM) report, To Err Is Human: Building a Safer Health System , the problems associated with injury
-
preventiveservices.ahrq.gov/patient-safety/settings/hospital/red/toolkit/index.html
April 01, 2023 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI