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181. Table 17B: Dually Eligible HCBS Participants | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17b.html
     February 01, 2023 - 10,530 7,005 Composite: ACSC Overall 24,760 16,334 23,622 19,729 26,330 18,086 Pressure … 397 350 396 366 462 324 Outcome Indicator Prevalence of High Blood Pressure … 8,314 8,522 10,408 7,479 Composite: ACSC Overall 21,408 21,005 25,803 19,316 Pressure

182. Table 17G: HCBS Population Age 65 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17g.html
     February 01, 2023 - 13,941 8,615 Composite: ACSC Overall 31,820 19,437 32,312 23,141 34,235 21,902 Pressure … 568 461 588 484 677 430 Outcome Indicator Prevalence of High Blood Pressure … 10,221 11,658 13,626 9,337 Composite: ACSC Overall 25,759 28,549 32,778 23,897 Pressure

183. Table 17D: Intellectual/Developmental Disabilities Subpopulation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17d.html
     February 01, 2023 - 3,815 3,120 Composite: ACSC Overall 6,079 4,558 5,662 5,312 6,245 5,000 Pressure … Falls 81 60 90 55 92 60 Outcome Indicator Prevalence of High Blood Pressure … 3,481 3,208 3,831 3,228 Composite: ACSC Overall 5,719 5,011 6,399 5,136 Pressure

184. Table 17C: Medicaid-Only HCBS Participants | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17c.html
     February 01, 2023 - 5,049 3,932 Composite: ACSC Overall 15,281 10,642 14,988 12,306 15,447 12,117 Pressure … Falls 76 51 101 45 98 47 Outcome Indicator Prevalence of High Blood Pressure … 4,416 4,102 5,111 4,002 Composite: ACSC Overall 13,885 11,778 15,231 12,519 Pressure

185. Table 17A: National HCBS Population | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17.html
     February 01, 2023 - 9,215 6,184 Composite: ACSC Overall 22,374 14,832 21,534 17,751 23,720 16,492 Pressure … 316 271 324 280 375 250 Outcome Indicator Prevalence of High Blood Pressure … 7,298 7,429 9,114 6,570 Composite: ACSC Overall 19,447 18,724 23,221 17,538 Pressure

186. Chartbook on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2020.pdf
     January 01, 2020 - pertaining to nine patient safety event types that represent the majority of reported preventable injuries … captures the specific type of physical injury sustained in the fall as TYPE OF INJURY AS RESULT OF … that they represent minor injuries such as soreness, bumps, and minor abrasions. … and the type of the injury. … unstageable A lesion that, on admission, was a suspected Deep Tissue Injury A pressure ulcer at stage

187. Table 17F: HCBS Population Ages 18-64 Without Intellectual/Developmental Disabilities or Serious Mental Illness | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17f.html
     February 01, 2023 - 7,139 5,429 Composite: ACSC Overall 23,940 16,507 25,790 18,529 23,803 18,978 Pressure … 147 123 175 119 170 116 Outcome Indicator Prevalence of High Blood Pressure … 6,119 6,072 7,171 5,539 Composite: ACSC Overall 21,607 19,235 23,468 19,546 Pressure

188. Table 17E: Serious Mental Illness Subpopulation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17e.html
     February 01, 2023 - 8,838 5,914 Composite: ACSC Overall 20,734 15,368 19,563 17,756 23,009 16,087 Pressure … 253 224 263 220 323 194 Outcome Indicator Prevalence of High Blood Pressure … 6,956 7,098 7,925 6,580 Composite: ACSC Overall 19,175 17,427 20,509 17,826 Pressure

189. Communication: Severe Hypertension (pdf file)
     www.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

190. PS Grantee | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/index.html?page=8
     January 01, 2024 - Publication Date: March 2015 Using an Electronic Health Record To Examine Nurse Continuity and Pressure … Coordination, Health Information Technology and Health Information Exchange, Human and Environmental Factors, Pressure … Information Exchange Publication Date: December 2014 Communication To Prevent and Respond to Medical Injuries

191. Challenges to Real-Time Decision Support in Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Fitzgerald_108.pdf
     January 01, 2007 - of patient injury. … The site and extent of injuries are unknown during the initial minutes after the patient is admitted … Evaluation of a blunt and penetrating trauma algorithm for truncal injury. … Injury 2005; 36: 905-911. 11. McDermott FT, Cordner SM, Tremayne AB. … Missed injuries in a level 1 trauma center.

192. On World Patient Safety Day, AHRQ Highlights the Urgent Need to Address Diagnostic Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/blog/ahrqviews/world-patient-safety-day-2024.html
     September 01, 2024 - common individual adverse events for populations with sufficient size for analysis were: 1) worsening pressure … injuries that were present on admission (2021: 4.9 percent, 2022: 6.0 percent), 2) hypoglycemic events

193. Clinical Informatics and Its Usefulness for Assessing Risk and Preventing Falls and Pressure Ulcers in Nursing Home Environments (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Teigland.pdf
     March 01, 2004 - observed, “Medicare is spending billions to treat preventable (fall) injuries…at an average cost of … Medicare could realize substantial savings if these injuries could be prevented.”15 Prevention of pressure … billion.17 Falls and pressure ulcers are often avoidable. … average cost of $1,272 per injury14 and assuming conservatively that one out of ten falls results in injury … Preventing Falls and Pressure Ulcers 85 12. Dyck MJ.

194. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits Training | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereportguide.html
     September 01, 2017 - Infected wound or decubitus. Jaundice. Rash. Fall-Related Injury. … Wound or skin issues. Fall-related injury. Non-fall-related injury. Abnormal labs. … Fall/trauma. Anemia. Diabetes. … Wound or skin issues. Fall-related injury. Non-fall-related injury. Abnormal labs. … Fall/trauma. Anemia. Diabetes.

195. AHRQ Quality Indicators Prioritization Worksheet Example (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.pdf
     June 02, 2025 - Postoperative Sepsis 12.7 11.7 15 $49,215 $ 738,225 N 9 7 3 Y Y Y Y Y PSI 14 Postoperative Wound … - Injury to Neonate 0.0 0.1 0 $88,000 $ - N 2 3 9 Y Y Y Y Y PSI 18 Obstetric … Trauma-Vaginal Delivery With Instrument 134.8 135.1 17 $90,000 $ 1,530,000 N 2 3 8 Y Y … Y Y Y PSI 19 Obstetric Trauma-Vaginal Delivery Without Instrument 17.0 17.9 5 $96,000 $ … Rate 0.0 16.2 0 $117,815 $ - N 9 10 10 Y Y Y Y Y PDI 11 Postoperative Wound

196. Chapter 5. Information and Training for Staff, Primary Care Providers, and Residents and their Families | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man5.html
     December 01, 2017 - (number of falls, number of fallers, number of residents with 2 or more falls and number of serious injuries … Use Low Blood Pressure Precautions

197. On-Time Preventable Hospital and ED Visits Functional Specs (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevhospitalvisits-funcspecs_0.pdf
     August 01, 2017 - Ulcer Vendor determined or Wound Assessment Pressure ulcer Stage II, III, IV, or unstageable. … IF wound assessment date ≤7 days of report date AND at least one pressure ulcer with ulcer stage = … then display X in Wound • Infected wound or decubitus ulcer • Jaundice • Rash 10 Injury: Fall … X in Injury: 11 Injury: Non- Fall Related Transfer Note • • Major injury Minor injury IF …  Chest pain/angina  Dizzy/lightheaded Non-Fall-Related Injury  Major injury  Minor injury

198. Table 10: Outcome Indicators by Selected Home and Community-Based Services 1915(c) Waiver Services Offered, 2005 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab10.html
     February 01, 2023 - Composite: ACSC Overall Yes 22,422 20,395 25,160 No 18,138 19,018 17,666 Pressure … 7,607 Composite: ACSC Overall 20,384 19,444 14,877 19,094 19,184 20,443 Pressure

199. Preventing Pressure Ulcers in Hospitals: A Toolkit - Section 7, Tools and Resources (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressureulcertoolkit/putoolssect7.pdf
     January 01, 2004 - Pressure ulcers are sterile wounds. 36. … Pressure ulcers are sterile wounds. False 36. …  If a skin disruption is found, the type of skin injury will need to be identified. … For example is it a skin tear, a pressure ulcer, or moisture-associated skin damage or injury? … medical staff, wound team, and unit staff for pressure ulcer practice Certified Wound Care Nurse

200. Chartbook on Hispanic Health Care: Slide Presentation—Part 2 | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/hisph-slides-pt2.html
     May 01, 2018 - Slide 39 Maternity Care for Hispanics Note: Trends: Birth trauma and obstetric trauma were … Slide 43 Birth trauma—injury to neonate per 1,000 live births, by race/ethnicity, 2004-2012 Image … : Graph shows birth trauma—injury to neonate per 1,000 live births: Year Total White Black … Note: Trends: Birth trauma-neonatal injury rates fell from 2.6 per 1,000 live births in 2004 … Between 2004 and 2012, birth trauma-neonatal injury rates fell for all racial/ethnic groups.