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241. Appendix 3-A. Suggested Slides for Module 3 | Agency for Healthcare Research and Quality
     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).

242. Improving Patient Safety in Long-Term Care Facilities, Module 3 (pdf file)
     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

243. Communication: Severe Hypertension - PowerPoint Presentation
     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. 

244. Chartbook on Hispanic Health Care: Slide Presentation | Agency for Healthcare Research and Quality
     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

245. SOPS Nursing Home Survey: What You Need To Know - Nicholas Castle, Ph.D., M.H.A., FGSA (pdf file)
     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

246. Fact Sheet on Patient Safety Indicators (pdf file)
     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

247. Final Progress Report: Using an Electronic Health Record to Examine Nurse Continuity and Pressure Ulcers (pdf file)
     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.

248. Technical Interventions To Prevent CAUTI | Agency for Healthcare Research and Quality
     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

249. Overuse of Imaging for the Evaluation of Children with Simple Febrile Seizure: Tables 1 - 10 (pdf file)
     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

250. IQI, PSI, AND PDI RATES GENERATED BY THE AHRQ WINDOWS QI SOFTWARE (pdf file)
     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

251. 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

252. Table A: Indicator Rates for the HCBS and Full Medicaid Populations (Rates of Admission per 100,000 Persons) | Agency for Healthcare Research and Quality
     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

253. 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.

254. 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

255. 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

256. 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.

257. 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

258. 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.

259. 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

260. 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