-
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
-
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
-
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
-
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.
-
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.
-
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.
-
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
-
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.
-
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
-
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
-
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
-
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
-
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
-
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.
-
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 trauma—injury 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 trauma—injury
-
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
-
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 injury … Pressure 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.
-
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
-
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
-
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