-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19d.html
March 01, 2023 - 3,685
2,830
Composite: ACSC Overall
6,401
5,144
6,083
4,903
6,049
4,408
Pressure … 3,503
3,242
3,720
2,668
Composite: ACSC Overall
5,768
5,111
6,087
4,163
Pressure
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19c.html
March 01, 2023 - 4,435
3,912
Composite: ACSC Overall
14,847
12,685
13,750
12,591
14,039
10,413
Pressure … 4,284
4,429
4,470
3,725
Composite: ACSC Overall
13,151
13,631
14,134
9,746
Pressure
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19b.html
March 01, 2023 - 8,456
8,118
Composite: ACSC Overall
25,741
19,330
21,845
20,450
21,888
19,402
Pressure … 8,162
8,798
8,469
8,012
Composite: ACSC Overall
20,856
22,154
22,042
18,402
Pressure
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19.html
March 01, 2023 - 7,387
7,164
Composite: ACSC Overall
23,095
17,584
19,743
18,467
19,802
17,363
Pressure … 7,138
7,741
7,427
6,977
Composite: ACSC Overall
18,821
20,092
19,980
16,312
Pressure
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab11.html
February 01, 2023 - Overall
Yes
14,177
28,212
18,788
9,372
No
19,380
19,211
19,521
20,716
Pressure … Composite: ACSC Overall
50,783
40,549
9,972
20,001
18,997
10,923
20,108
19,218
Pressure
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-erepguide.pdf
February 10, 2014 - Healing
Weekly Wound Rounds Report
Weekly Pressure Ulcer Treatment Summary Report
Pressure … home chains, and wound centers. … Injury Alliance. … The wound nurse, wound
physician, and other disciplines attending wound rounds can see
quickly which … Treatments
Wound Cleanser.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b3a_combo_chartsforpresentations.xlsx
January 01, 2006 - 0.1493487343 PSI 12 Statistically Lower 0
PSI 13 Postoperative sepsis 17.433 0
PSI 14 Postoperative wound … 0.0683602771 PSI 15 Statistically Lower 0
PSI 16 Transfusion reaction 0.000004 0
PSI 17 Birth trauma … - injury to neonate 2.188 0
PSI 18 Obstetric trauma - vaginal with instrument 0.139241 0.062898 … 0.215583 133.928 -99.8960329431 0.0570030165 0.0570022699 PSI 18 Statistically Lower 0
PSI 19 Obstetric trauma … 0.01989 -100 -100 117.3881347411 PDI 10 No Statistically Significant Difference 0
PDI 11 Postoperative Wound
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmodap3a.html
October 01, 2014 - Nursing staff must have the knowledge and skills to prevent injury from falls. … Things about the equipment or care plan (e.g., monitor blood pressure frequently).
-
www.ahrq.gov/healthsystemsresearch/hspc-research-study/appendix-b.html
June 01, 2020 - Examples of intermediate outcomes include clinical health measures (e.g., adequate control of blood pressure … Intermediate outcomes include measures related to the incidence of chronic conditions—such as high blood pressure … This category includes studies of population health, injury occurrence, and disease progression. … Examples of intermediate outcomes of care are blood pressure, asthma, and glycemic control. … that primarily examine how to treat injuries or disease (even if the injury or disease is preventable
-
www.ahrq.gov/sites/default/files/publications/files/ltcmodule3.pdf
June 01, 2012 - He has moderate dementia, and his blood pressure falls when
he stands up too fast, making him dizzy. … However, what we can do is eliminate needless falls and
limit the injuries from falls that do occur. … Relationship between physical restraint removal and falls
and injuries among nursing home residents. … Things about equipment or the care plan, including:
› More frequent blood pressure monitoring.
› More … resident (e.g., review
medications).
› Things about the equipment or care plan
(e.g., monitor blood pressure
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_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, … Smith so you can treat her severe blood pressure and draw labs. … Smith, you do not have severe-range blood pressure at this time.
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-nh_webcast-castle.pdf
January 01, 2006 - Hospitals
►Moving, Transferring, or Lifting Residents
►Medication errors
►Falls
►Pressure ulcers
►Sanitation … Patient Safety Culture in Nursing Homes
• Safety culture influences staff as well as residents
► Overall injury
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a1b_combo_psifactsheet.pdf
October 01, 2015 - Year
PSI 02 Death Rate in Low-Mortality Diagnosis-
Related Groups (DRGs)
0.32 0347 2012
PSI 03 Pressure … Thrombosis Rate
4.99 0450 2012
PSI 13 Postoperative Sepsis Rate 9.61
PSI 14 Postoperative Wound … Laceration Rate X 1.89 0345 2012
PSI 16 Transfusion Reaction Count X N/A* 0349 2012
PSI 17 Birth Trauma … Rate – Injury to Neonate 1.89
PSI 18 Obstetric Trauma Rate – vaginal delivery
with instrument … 133.19
PSI 19 Obstetric Trauma Rate – vaginal delivery
without instrument
20.97
PSI 90
-
www.ahrq.gov/hai/cauti-tools/guides/implguide-pt3.html
October 01, 2015 - ulcers or similarly severe wounds that cannot be kept clear of urinary incontinence despite wound care … require strict prolonged immobilization following specific types of trauma or surgery. … Examples include instability in the thoracic or lumbar spine, multiple traumatic injuries such as pelvic … Intermittent catheterization is most often used in patients with neurogenic bladder or spinal cord injury … despite wound care and other urinary management strategies, if ISC is adequate to manage the type of
-
www.ahrq.gov/sites/default/files/2024-01/stifter-report.pdf
January 01, 2024 - outcomes are limited, depicting some negative findings, including increased errors,62-63 needle stick
injuries … With the ongoing financial pressures faced by hospitals, the erosion of
nursing services will continue … Work schedule, needle use and needle
stick injuries among registered nurses. … Hospitalizations related to pressure ulcers among adults 18
years and older. … Pressure ulcers: A patient safety issue.
-
www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/hisph-slides.html
March 01, 2020 - Slide 61
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. … Injuries: Any external cause of injury code indicating motor vehicle accident and unintentional injuries
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b2b_combo_ratesgenbywin.pdf
March 01, 2016 - Rate 0 0 - 0.0006572
PDI1 PDI #1 Accidental Puncture or Laceration Rate 0 0 - 0.00053522
PDI2 PDI #2 Pressure … Count 0 - - -
PSI2 PSI #2 Death Rate in Low-Mortality DRGs 8 132 0.06060606 0.00028197
PSI3 PSI #3 Pressure … Rate – Injury to Neonate 0 0 - 0.00210694
PSI18 PSI #18 Obstetric Trauma Rate – Vaginal Delivery With … Diagnosis Related Groups (DRGs)
8 132 0.060606 0.001046 57.95983 0.000282 0.016343 0.007641
PSI #3 Pressure … Rate - Injury
to Neonate
0.002107
PSI #18 Obstetric Trauma Rate -
Vaginal Delivery With
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0192-tables1-10.pdf
June 02, 2025 - 61106
Twist drill hole for subdural or ventricular puncture; for implanting ventricular catheter or pressure … intracerebral 61156
Burr hole(s); for implanting ventricular catheter, reservoir, eeg electrode(s), pressure … excision of foreign body from brain 61570
Craniectomy or craniotomy; with treatment of penetrating wound … Personal history of other certain diseases TIA and cerebral infarction V12.5
Table 9 [=IMG9]: Head Trauma … 852.x
Other/unspecified intracranial hemorrhage
following injury
853.x
Intracranial injury
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-measure-implementation.pdf
August 01, 2025 - The difference between home and ED systolic blood pressures was
not associated with anxiety and showed … These findings show that over half of
ED patients with 2 elevated blood pressures and no history of … measure pain and anxiety scores in the ED in an attempt to understand the
meaning of elevated blood pressures … Score (AIS)=5 head injury, other AIS=5 injury, or higher
age groups. … than
patients without a medical injury.
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/oirtab.html
December 01, 2012 - Composite: ACSC Acute Conditions
6,913
2,846
Composite: ACSC Overall
17,971
7,139
Pressure