-
teamstepps.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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teamstepps.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
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teamstepps.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
-
teamstepps.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
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teamstepps.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes2.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
-
teamstepps.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html
June 01, 2022 - The Preventing Pressure Ulcers in Hospitals Toolkit assists hospital staff in implementing effective … pressure ulcer prevention practices through an interdisciplinary approach to care. … The toolkit draws on literature on best practices in pressure ulcer prevention and includes both validated … patients can suffer adverse outcomes and even fatal complications, and clinicians can be exposed to injury
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teamstepps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/guides/guide-infection-prevention.pdf
March 01, 2017 - ▪ Infections cause pain, injury, disability, and sometimes even
death, and can be very expensive … ▪ Cover all cuts and wounds with a dressing. … resident, if needed, that the law requires the use of safety lancets and needles
to prevent needle stick injuries … ▪ Make sure that wounds are covered.
▪ Contain any urine, stool, or wound drainage. … ▪ An LTC facility must have negative pressure rooms and a respiratory fit-test program in order
to
-
teamstepps.ahrq.gov/challenges/data-visualization/index.html
February 01, 2024 - higher prevalence of HIV in men who have sex with men), or socioeconomic factors (e.g., higher blood pressure … the Federal Government and its related entities, except in the case of willful misconduct, for any injury … whether direct, indirect, or consequential, arising from participation in this prize contest, whether the injury
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teamstepps.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-4/guide.html
October 01, 2017 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … Critical Thinking for Fall Injury Prevention —AHRQ Fall Prevention Program Implementation Sharing Webinar
-
teamstepps.ahrq.gov/research/findings/making-healthcare-safer/comparison.html
September 01, 2022 - Evidence
(Not reviewed)
(Not reviewed)
Interventions To Prevent Contrast-Induced Acute Kidney Injury … Summary of Evidence
Update
(all patients)
(Not reviewed)
Preventing Patient Death or Serious Injury … Institutionalized Older People
Summary of Evidence
Update
(all patients)
(Not reviewed)
Prevention of Pressure
-
teamstepps.ahrq.gov/news/blog/ahrqviews/defining-new-ahrq.html
January 01, 2021 - HAC events amount to more than $28 billion in excess healthcare costs, including pressure ulcers ($9.9 … nurses and other healthcare professionals remains a significant and troubling issue, as do workplace injuries
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teamstepps.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.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
-
teamstepps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-comm-assessment.pdf
April 01, 2016 - Eventually, they are able to re-establish a normal heart rate, blood pressure, and adequate blood
oxygen … During her procedure, her heart rate, blood pressure, and oxygen level were monitored. … During a part of
the procedure, we became aware that her heart rate, blood pressure, and oxygen level … First off, right now Mary
is stable; her heart rate, blood pressure, and oxygen level are all in normal … We also don’t know right now if she has
suffered any injury from what happened, but we will check her
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teamstepps.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes6.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
-
teamstepps.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.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 … The event review focuses on uncovering latent hazards or contributing factors that increase pressure
-
teamstepps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module2/module2_fall-prevention.docx
August 24, 2017 - applied to other quality improvement efforts in a hospital, such as preventing:
Hospital-acquired pressure … injuries.
-
teamstepps.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023-NHQDR-appendixes-ACDE-rev.pdf
January 01, 2023 - 1,000 elective-surgery admissions, age
18 and over
HCUP 2020
Reclosure of postoperative abdominal wound … 2020
Home health care patients whose management of oral
medications improved
OASIS 2021
Birth trauma … stages 2-4
pressure ulcer or unstageable pressure ulcer
MDS 2021
Low-risk, long-stay nursing home … 2020
Home health care patients whose management of oral
medications improved
OASIS 2021
Birth trauma … stages 2-4
pressure ulcer or unstageable pressure ulcer
MDS 2021
Low-risk, long-stay nursing home
-
teamstepps.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/2017qdr-patsafchartbook.pdf
October 01, 2018 - per 1,000 instrument-assisted deliveries
• Birth trauma - injury to neonate per 1,000 selected live … 40
60
80
100
2014 2015 2016 2017 2018 2019 GOAL
Ra
te
p
er
1
,0
00
D
is
ch
ar
ge
s
Pressure … 40
60
80
100
2014 2015 2016 2017 2018 2019 GOAL
Ra
te
p
er
1
,0
00
D
is
ch
ar
ge
s
Pressure … Adverse Drug Events
• An adverse drug event (ADE) is an injury—including physical harm, mental harm, … The home health team should regularly change wound dressing and teach the patient about
wound care.
-
teamstepps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module2/module2_tools.docx
November 16, 2011 - Monthly falls analysis by:
location and time of fall
shift and day of week
type of injury … consequences of falls
High-risk medications, sleep hygiene measures for management of anxiety
Low blood pressure
-
teamstepps.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/afib_topicref.pdf
January 01, 2020 - peripheral vascular
complication [including pseudoaneurysm,
hematoma at catheter insertion site, vascular
injury