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241. CHIPRA 194: Section 1, Tables 1-5 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-194-section-1-tables-1-5.pdf
     June 02, 2025 - thunderclap 339.43 Other complicated 339.44 Other Post-traumatic headache 339.2x Acute pain due to trauma … seizure 780.33 Other convulsions 780.39 4 Table 4 [=IMG9]: ICD-9-CM Codes to Identify Head Trauma … 852.x Other/unspecified intracranial hemorrhage following injury 853.x Intracranial injury of other … 61106 Twist drill hole for subdural or ventricular puncture; for implanting ventricular catheter or pressure … excision of foreign body from brain 61570 Craniectomy or craniotomy; with treatment of penetrating wound

242. The Relationship Between Hospital Workload and Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/weissman-rothschild-report.pdf
     January 01, 2024 - Structured Abstract Purpose: Aim 1 of this study was to determine the extent to which hospital workload pressures … this study was to determine the extent to which hospital working conditions, specifically workload pressures … Operative organ injury Operative blood or lymph vessel injury or postoperative hemorrhage Postoperative … Adverse drug events and specific hospital-acquired infections (bloodstream, urinary tract, wounds, respiratory … Thus, seven wounds were missed by computerized surveillance when study patients had positive culture

243. Views of Emergency Medicine Trainees on Adverse Events and Negligence: Survey Results from an Emergency Medicine Training Program in a Regional Health Care System Following the National Standard of 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-Shah_99.pdf
     March 23, 2008 - Two of these EDs are Level 1 Trauma Centers. … An adverse event was defined as “an injury caused by medical management error rather than the patient … The feeling of pressure from a day-to-day threat of malpractice litigation, as well as the ordering … Negligence may or may not produce patient injury; the former product is called an adverse event due to … The questionnaire used examples of adverse event injuries, but it did not consider threshold levels.

244. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereports.html
     September 01, 2017 - Presence of stage II or greater pressure ulcer. Fall risk or previous fall in last 90 days. … and skin, injury (fall related or not fall related), musculoskeletal, abnormal labs or anemia, fever … or skin issues Fall-related injury Non-fall-related injury Abnormal labs Fever/possible infection … disease Asthma Circulatory problems Hypertension Gastroenteritis Angina pectoris Falls/trauma … obstructive pulmonary disease, asthma, circulatory problems, hypertension, gastroenteritis, angina, falls/trauma

245. Final Progress Report: Producing Evidence: Coordination within a Multiteam System Makes Healthcare Safer (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/jones2-report.pdf
     January 01, 2024 - ,3 with an average associated excess cost of $7,000 per injury.4 Regardless of injury, falling can lead … .35 Consequently, randomized controlled trials of individual processes, such as use of bed/chair pressure … Supervisor/Manager Expectations & Actions Promoting Patient Safety (α = .92) 83 80 .88 Whenever pressure … REFINE (REducing Falls in In-patieNt Elderly) using bed and bedside chair pressure sensors linked to … Circumstances of patient falls and injuries in 9 hospitals in a Midwestern healthcare system.

246. Standardized infection ratios for central line-associated bloodstream infections and surgical site infections, 2009–2012
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2014chartbooks/hispanichealth/2014nhqdr-hispanichealth-pt2.pptx
     July 01, 2015 - chemical dependency (measured by deaths due to cirrhosis); diabetes; homicide and accidents (unintentional injuries … - injury to newborn per 1,000 live births Better No Change Obstetric trauma per 1,000 vaginal deliveries … 4.5 4.4000000000000004 4.4000000000000004 4.0999999999999996 4.3 Rate per 1,000 Live Births Birth trauma—injury … Trends: Birth trauma-neonatal injury rates fell from 2.6 per 1,000 live births in 2004 to 1.9 per 1,000 … Between 2004 and 2012, birth trauma-neonatal injury rates fell for all racial/ethnic groups.

247. Mercy Health Uses AHRQ's Patient Safety Culture Survey and TeamSTEPPS® to Enhance Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/201411.html
     August 01, 2014 - Mercy also replaced patient beds to reduce incidents of pressure ulcers and to promote patient and staff … Implementing the "Minimal Lift Program," which is designed to reduce injuries resulting from repositioning

248. Prevehosp-Reports-Ig (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevehosp-reports-ig.pdf
     November 30, 2013 -  Major injury  Minor injury Non-Fall-Related Injury  Major injury  Minor injury Musculoskeletal … o Rash  Fall-Related Injury:. … , an “X” will display in this column: o Major injury o Minor injury  Non-Fall-Related Injury. …  Asthma  Circulatory problems  Hypertension  Gastroenteritis  Angina pectoris  Fall/trauma … cellulitis, dehydration, COPD, asthma, circulatory problems, hypertension, gastroenteritis, angina, falls/trauma

249. Methods To Estimate the Baseline 2010 PFP National Hospital-Acquired Condition Rate | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/methods.html
     December 01, 2017 - Catheters Falls MPSMS In-Hospital Patient Falls Obstetric Adverse Events PSI OB Trauma … Pressure Ulcers Surgical Site Infections NHSN SSIs combined for 17 procedures based on CDC … The national number of adverse events captured by PSIs 18 and 19 on obstetric injury , and the national … Ulcers Hospital-Acquired Pressure Ulcers 53.03 62.45 0.85 VAP Ventilator-Associated … In-Hospital Patient Falls 262,317 32,750,000 8.010 Obstetric Adverse Events PSI OB Trauma

250. Final Progress Report: Transdisciplinary Learning Lab To Eliminate Patient Harm and Reduce Waste (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/sapirstein-report.pdf
     January 01, 2025 - A PUP CONOPs outlined key operational needs, metrics, and use cases for pressure ulcer prevention. … As a final step, methods and findings from the pressure injury use case were fed back into the CONOPS … conducted over the course of several workshops, utilizing the clinical expertise key stakeholders in wound … critical, life-threatening conditions receive constant monitoring and therapy to prevent significant injuries … The Financial Impact of Pressure Ulcers (White paper).

251. Overuse of Computed Tomography Scans for the Evaluation of Children with Atraumatic Headache: Report (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-206-fullreport.pdf
     November 01, 2019 - measure, atraumatic headaches are considered to be primary headaches or secondary headaches unrelated to injury … These complications include compromised airway, hypoxia leading to central nervous system injury, and … deep sedation carry a greater risk of airway compromise, hypoxia resulting in central nervous system injury … These risks include dental trauma; airway edema (swelling of the windpipe); vocal cord spasm or injury … ; regurgitation of stomach contents with subsequent aspiration (inhalation) pneumonia; injury to arteries

252. Final Progress Report: Pediatric Emergency Assessment Tool (pdf file)
     www.ahrq.gov/sites/default/files/2024-10/gorelick-report.pdf
     January 01, 2024 - The majority of these are intended for use in trauma patients, including the Injury Severity Score, … Trauma Score, and Pediatric Trauma Score. 35 Others are available for asthma,36 croup,37 and febrile … intravenous fluids • oxygen • prescription medications administered in ED (oral, IV, or inhaled) • wound … The Injury Severity Score: a method for describing patinets with multiple injuries and evaluating … The Injury Severity Score is unable to differentiate between poor care and severe injury.

253. Risk-Based Patient Safety Metrics (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Scanlon_62.pdf
     March 25, 2008 - human error,” and people make such attributions with all of their biases and under different kinds of pressures … an injury occurs. … Ideally, a patient safety program would use injury-based metrics to calculate an injury rate that could … That rate would be: Identified injuries Potential opportunities for those injuries to occur As … Identified injuries also become a source of risk identification, regardless of whether or not the injury

254. Session 1 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod3sess3.html
     October 01, 2014 - He has moderate dementia, and his blood pressure falls when he stands up too fast, making him dizzy. … Safety means avoiding, preventing, and lessening the effects of harm and injury while residents are in … To prevent injury from falls, all nursing staff need knowledge and skills. … Nursing staff must have the knowledge and skills to prevent injury from falls. … Injury Prevention and Control: Home and Recreational Safety; Falls in Nursing Homes.

255. Table 8B: Dually Eligible HCBS Participants | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8b.html
     February 01, 2023 - 19,884   Min 8,723 s s s s   Max 39,914 44,860 74,074 109,091 s Pressure … 11,656 7,935 10,256   Max 34,059 41,284 22,863 50,576 50,856 32,463 44,228 Pressure

256. Table 8C: Medicaid-Only HCBS Participants | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8c.html
     February 01, 2023 - 12,152   Min 3,503 s s s s   Max 29,139 28,882 33,333 57,143 s Pressure … s s 3,109 s   Max 19,830 35,256 29,840 68,293 96,970 25,549 36,882 Pressure

257. Table 8E: Serious Mental Illness Subpopulation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8e.html
     February 01, 2023 - 15,175   Min 9,170 s s s s   Max 49,738 48,185 50,000 88,889 s Pressure … s 5,975 8,746   Max 44,606 51,218 33,445 80,351 102,632 52,215 42,172 Pressure

258. Table 8G: HCBS Population Age 65 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8g.html
     February 01, 2023 - 23,974   Min 13,559 s s s s   Max 51,766 57,143 95,238 65,509 s Pressure … 11,836 13,626 18,523   Max 54,523 48,091 s 49,755 49,129 42,431 53,347 Pressure

259. Table 8A: National HCBS Population | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8.html
     February 01, 2023 - 17,845   Min 7,027 9,302 s s s   Max 36,997 40,253 41,379 51,572 s Pressure … 11,836 6,378 8,163   Max 29,607 39,709 25,788 49,755 49,129 29,454 42,207 Pressure

260. Table 8D: Intellectual/Developmental Disabilities Subpopulation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8d.html
     February 01, 2023 - 4,484   Min 2,636 s s s s   Max 10,521 14,248 15,129 53,571 s Pressure … 7,984 s 1,713 s   Max 9,546 12,167 7,955 38,424 95,652 9,389 12,785 Pressure