-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8f.html
February 01, 2023 - 22,643
Min
s
s
s
s
s
Max
42,799
51,459
68,293
75,000
s
Pressure … 5,672
s
s
3,977
6,993
Max
41,783
55,696
50,219
s
s
49,115
47,727
Pressure
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/pfphac.pdf
September 01, 2014 - With Central Venous 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 NHSN data … 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
Pneumonia … Falls MPSMS In-Hospital Patient Falls 262,317 32,750,000 8.010
Obstetric
Adverse Events
PSI OB Trauma
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www.ahrq.gov/sites/default/files/2024-11/gershon-report.pdf
January 01, 2024 - Nearly one of four RNs (19%,
n=142) reported experiencing an injury in the past 3 years. … The majority of these injuries were back injuries, (n=68, 48%),
upper-extremity injuries (n=38, 27%) … , and lower extremity injuries (n=37, 26%). … Of those with a fire extinguisher, only two households had a fire extinguisher with a working pressure … Childhood injury prevention at home and play.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a2_combo_boardpresentation.pdf
October 01, 2015 - October 2015:
– Addition of information relevant to ambulatory and managed
care encounters
– Expanded injury … • Several exclusions (e.g., length of stay <5 days,
principal diagnosis of pressure ulcer). … • Several exclusions (e.g., length of stay <5 days,
principal diagnosis of pressure ulcer). … A PSI Example: Pressure Ulcer (PSI 03)�
What are the Inpatient Quality Indicators (IQIs)? … An Example: Pressure Ulcer (PDI 02)�
How can the AHRQ QIs be used in quality assessment?
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www.ahrq.gov/hai/pfp/haccost2017-ref.html
May 01, 2023 - Costs of venous thromboembolism, catheter-associated urinary tract infection, and pressure ulcer. … The costs of medical falls by component of cost, timing, and injury severity. … Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization … Ostomy Wound Manage . 2016 Nov;62(11):30-8.
65. Mendizabal A, Thibault DP, Willis AW. … Marginal hospital cost of surgery-related hospital-acquired pressure ulcers.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/a2_pdi_boardpresentation.pdf
October 01, 2015 - October 2015:
– Addition of information relevant to ambulatory and managed
care encounters
– Expanded injury … /TechSpecs/PDI%2002%20Pressure%20Ulcer
%20Rate.pdf
• Numerator: Discharges with ICD-10-CM code of
pressure … • Several exclusions (e.g., length of stay <5 days,
principal diagnosis of pressure ulcer). … An Example: Pressure Ulcer (PDI 02)
http://www.qualityindicators.ahrq.gov/Downloads/Modules/PDI/V45/ … An Example: Pressure Ulcer (PDI 02)�
How can the AHRQ PDIs be used in�quality assessment?
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www.ahrq.gov/sites/default/files/2025-05/goldman2-report.pdf
January 01, 2025 - constraints impact the coordination and delivery of care, and patients suffer unexpected
complications and injuries … sequence of preceding events, the specific end states that are modeled can range from a
specific patient injury … Blood pressure regulatory functions are modeled as a subsystem of both the mother
and the fetus. … A common initiating event or failure is blood pressure lability that can ultimately
lead to one or more … Risk is perhaps best depicted as a dynamic situation in which two events –
progression to injury and
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-195-section-2.pdf
January 01, 2016 - seizure or convulsions associated with trauma
History of loss of consciousness associated with trauma … neurologic examination or signs or symptoms of intracranial
hemorrhage or increased intracranial pressure … Documentation of trauma
☐Yes ☐No
2b. … Mark “Yes” for mechanisms of injury such as penetrating trauma, fall from more than 5 feet, pedestrian … abnormal neurologic examination, signs and symptoms of intracranial
hemorrhage or increased intracranial pressure
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0198-tables1-9.pdf
June 02, 2025 - seizure 780.32
Post-traumatic seizure 780.33
Other convulsions 780.39
Table 3 [=IMG9]: 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 … 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
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/scenarios.html
August 01, 2022 - Eventually the team is able to re-establish Mary's normal heart rate, blood pressure, and adequate blood … During the resuscitation efforts, information obtained from the devices monitoring Mary's EKG, blood pressure … Over the next few days, it is clear that he has suffered a significant brain injury due to the lack of
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/find5.html
December 01, 2012 - higher rates on all measures other than Short-Term Complications of Diabetes, Bacterial Pneumonia, and Pressure … The exceptions are Pressure Ulcer, which is effectively equal in urban and nonurban areas, and Infection … Rates for women in the Medicaid-only population are always higher than for men except in Pressure Ulcer … The main exception to the county-level age pattern is the Pressure Ulcer measure, for which rates are … The pattern is strong for all conditions except high blood pressure.
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www.ahrq.gov/research/findings/nhqrdr/chartbooks/healthyliving/healthyliving-slides.html
April 01, 2018 - Patient Safety:
Birth trauma—injury to neonates. … Birth trauma not elsewhere classified. 24
Many of these injuries to neonates may be preventable … . 25
Slide 42
Birth trauma—injury to neonate per 1,000 live births, 2004-2013
Image: Chart … Overall Rate: In 2013, the birth trauma-neonatal injury rate was 1.9 per 1,000 live births. … Birth Trauma Rate—Injury to Neonate: Technical Specifications.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/a2_pdi_boardpresentation.pptx
October 01, 2015 - Rate
NQI 03 Neonatal Blood Stream Infection Rate
PDI 01 Accidental Puncture or Laceration Rate
PDI 02 Pressure … PDI 09 Postoperative Respiratory Failure Rate
PDI 10 Postoperative Sepsis Rate
PDI 11 Postoperative Wound … in October 2015:
Addition of information relevant to ambulatory and managed care encounters
Expanded injury … Several exclusions (e.g., length of stay <5 days, principal diagnosis of pressure ulcer). … An Example: Pressure Ulcer (PDI 02)
Tool A.2 Slide ‹#›
Pediatric Toolkit for Using the AHRQ Quality
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module5-presenters-notes.pdf
January 10, 2022 - It
also ensures staff are supported in times of stress or production pressures or when
the day is just … or
unfolding error
An opportunity to
interrupt or correct
an action or event
before harm or
injury … and teams to take steps to interrupt or correct an action or event
before harm or injury … Are the blood pressure cuffs,
otoscope, ophthalmoscopes, and other equipment working properly? … Are
things being left undone because of time pressure?
-
www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module5-situation-monitoring.pptx
January 10, 2022 - It also ensures staff are supported in times of stress or production pressures or when the day is just … allows individuals and teams to take steps to interrupt or correct an action or event before harm or injury … risk or unfolding error
An opportunity to interrupt or correct an action or event before harm or injury … Are the blood pressure cuffs, otoscope, ophthalmoscopes, and other equipment working properly? … Are things being left undone because of time pressure?
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Blike.pdf
January 01, 2003 - Elimination of sedation errors is particularly important since associated deaths
and neurological injuries … review of 90 pediatric sedation-
related critical incidents resulting in death or severe neurological injury … This report has served
as a warning that pediatric patients are at especially high risk for injury during … They initially took over positive
pressure ventilation. … Assumed
RN had optimized positive
pressure ventilation.
-
www.ahrq.gov/sites/default/files/2024-02/goldstein-report.pdf
January 01, 2024 - Final Progress Report: Reduction of Nephrotoxic Medication-Associated Acute Kidney Injury in Children … rate
(per exposure) 20.8% 15.0% -28 15.4%
Acute kidney injury
Intensity rate
(Acute kidney injury … Effectiveness of home blood pressure monitoring, Web
communication, and pharmacist care on hypertension … Modified RIFLE criteria in critically ill children with acute
kidney injury. … Guideline for Acute Kidney Injury.
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-alternatives-notes.docx
April 01, 2022 - They are as follows:
· Stage III or stage IV or unstageable pressure ulcers
· Moderate to severe incontinence-associated … Intermittent catheterization is often used in patients with neurogenic bladder or spinal cord injury, … urinary retention with or without bladder outlet obstruction
· Stage III or stage IV or unstageable pressure … ulcer, or similarly severe wounds of other types, that cannot be kept clear of urinary incontinence … despite wound care and other urinary management strategies, if the ISC is adequate to manage the type
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-case-scenarios.pdf
April 01, 2016 - Eventually the team is able to
re-establish Mary’s normal heart rate, blood pressure, and adequate blood … During the resuscitation efforts, information obtained from the devices monitoring Mary’s EKG, blood pressure … Over
the next few days, it is clear that he has suffered a significant brain injury due to the lack
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/building-team-040814.pptx
January 01, 2013 - remove the catheter shortly after the surgery is completed
27
Assist Healing of Perineal and Sacral Wounds … end-of-life: depends on what the patient perceives as more comfortable
29
Required Immobilization for
Trauma … or Surgery
Examples include:
Unstable thoracic or lumbar spine
Multiple traumatic injuries, such … unit (e.g., congestive heart failure receiving diuretics )
Incontinence without sacral or perineal pressure … ICU, or different non-ICU)
Partnering with other stakeholders (case managers, physical therapists, wound