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  1. 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
  2. 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 TraumaPressure 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
  3. 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.
  4. 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?
  5. 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.
  6. 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?
  7. 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
  8. Overuse of Imaging (pdf file)

    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
  9. 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
  10. 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
  11. 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.
  12. www.ahrq.gov/research/findings/nhqrdr/chartbooks/healthyliving/healthyliving-slides.html
    April 01, 2018 - Patient Safety: Birth traumainjury to neonates. … Birth trauma not elsewhere classified. 24 Many of these injuries to neonates may be preventable … . 25 Slide 42 Birth traumainjury 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.
  13. 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
  14. 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?
  15. 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?
  16. 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.
  17. 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.
  18. 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
  19. Mod5-Case-Scenarios (pdf file)

    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
  20. 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

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