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  1. 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
  2. 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 pressureinjuries that were present on admission (2021: 4.9 percent, 2022: 6.0 percent), 2) hypoglycemic events
  3. 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
  4. 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.
  5. 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.
  6. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-ostomy.pdf
    June 02, 2025 - anchoring elements to bond the epidermis to the underlying dermis, so skin is more susceptible to friction injury … ■ Peristomal skin must be protected from mechanical trauma due to use of aggressive adhesives, improper … ■ Vent frequently to prevent gas pressure from compromising the seal.
  7. 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
  8. 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.
  9. www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab12.html
    February 01, 2023 - Composite: ACSC Overall Yes 26,515 17,685 7,028 No 18,855 19,300 20,127 Pressure … 7,404 Composite: ACSC Overall 6,233 33,102 8,819 20,714 16,992 19,479 Pressure
  10. 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
  11. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4g_pdi09-postoprespfailure-bestpractices.pdf
    May 17, 2016 - o Decreased central nervous system input (head injury, ingestion of central nervous system depressant … o Peripheral nerve/neuromuscular junction (spinal cord injury, organophosphate/carbamate poisoning, … expansion exercises with children, such as incentive spirometry, deep breathing, intermittent positive-pressure … breathing, and continuous positive airway pressure. … Noninvasive positive pressure ventilation for acute respiratory failure in children: a concise review
  12. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
    May 17, 2016 - o Decreased central nervous system input (head injury, ingestion of central nervous system depressant … o Peripheral nerve/neuromuscular junction (spinal cord injury, organophosphate/carbamate poisoning, … expansion exercises with children, such as incentive spirometry, deep breathing, intermittent positive-pressure … breathing, and continuous positive airway pressure. … Noninvasive positive pressure ventilation for acute respiratory failure in children: a concise review
  13. 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
  14. 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 traumainjury to neonate per 1,000 live births, by race/ethnicity, 2004-2012 Image … : Graph shows birth traumainjury 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.
  15. www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2014chartbooks/hispanichealth/2014nhqdr-hispanichealth-pt2.pdf
    July 01, 2015 - - injury to newborn per 1,000 live births Better No Change Obstetric trauma per 1,000 vaginal deliveries …  Trends: ■ Birth trauma-neonatal injury rates fell from 2.6 per 1,000 live births in 2004 to 1.9 … ■ Between 2004 and 2012, birth trauma-neonatal injury rates fell for all racial/ethnic groups. … Birth traumainjury to neonate per 1,000 live births, by race/ethnicity, 2004-2012 Key: API = Asian … 2011 2012 R at e p e r 1 ,0 0 0 L iv e B ir th s Total White Black API Hispanic Birth traumainjury
  16. 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
  17. www.ahrq.gov/npsd/data/dashboard/index.html
    September 01, 2024 - to falls, the presence of fall assistance, presence of fall assistance by patient harm, type of fall injuryPressure Ulcer Dashboard Details the documentation of increased risk for pressure ulcer following a risk … assessment; and the timing of the first risk assessment for reported pressure ulcers or sDTIs.  
  18. www.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
  19. www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab9.html
    February 01, 2023 - Overall Yes 18,922 20,115 18,052 19,228 No 28,131 18,583 22,752 19,363 Pressure … Composite: ACSC Overall 19,083 19,110 16,427 19,636 23,560 27,103 21,664 20,810 Pressure
  20. www.ahrq.gov/hai/tools/mvp/modules/technical/early-mobility-icu-fac-guide.html
    February 01, 2017 - These included: five falls to knees without injury, four with systolic blood pressure less than  90 mmHg … pressure less than 55 mmHg, and four cases of oxygen desaturation. … Slide 17: Early Mobility in a Trauma and Burns ICU Say: Clark et al. performed a retrospective … before and after cohort study, based on chart review, at an academic medical center in a trauma and burns … Slide 23: 5-Year Sustainability of Time to PT Postacute Lung Injury Diagnosis Say: In this chart

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