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281. Case Scenarios: Handling Challenging Communications | Agency for Healthcare Research and Quality
     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

282. Overuse of Computed Tomography Scans for the Evaluation of Children with a First Generalized Afebrile, Atraumatic Seizure: Tables 1-9 (pdf file)
     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

283. Chartbook on Healthy Living: Slide Presentation | Agency for Healthcare Research and Quality
     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.

284. NPSD Data Spotlight: Patterns of Fall Interventions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-patterns-fall-interventions.pdf
     September 01, 2023 - COMMON INTERVENTION(S) IN PLACE FOR PATIENTS WITH DIFFERENT DEMOGRAPHICS OR RISKS OF FALLS OR INJURIES … /Surgical Supply, Fall, Healthcare-Associated Infection, Medication or Other Substance, Perinatal, Pressure … health considerations.1–4 Falls result in significant physical and economic burden, ranging from injuries … Incidence of and county variation in fall injuries in US residents aged 65 years or older, 2016-2019 … Trends in fatal and nonfatal injuries among older Americans, 2004– 2017. Am. J. Prev.

285. Background for AHRQ Quality Indicators
     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

286. AHRQ Stats | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/ahrq-stats.html
     July 01, 2025 - , by Cause of Injury, 2017 .) … Trauma During Childbirth The rate of obstetric trauma during childbirth involving instruments such as … Decreasing Pressure Ulcers Among Hospital Patients The average rate of hospital-associated pressure ulcers … Pressure Ulcer Rates of Hospital Patients About 1.2 million cases of hospital-acquired pressure ulcers … highest average expenses per person were for the treatment of heart conditions ($3,794 per person), trauma-related

287. Module 5: Situation Monitoring
     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?

288. TeamSTEPPS® Diagnosis Improvement: Module 5 Situation Monitoring To Improve Diagnosis - Facilitator’s Notes (pdf file)
     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?

289. Standardized Simulated Events for Provocative Testing of Medical Care System Rescue Capabilities (pdf file)
     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.

290. 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

291. Final Progress Report: Reduction of Nephrotoxic Medication-Associated Acute Kidney Injury in Children (pdf file)
     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.

292. Nursing Intervention to Remove Non-necessary Urinary Catheters
     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

293. Central Venous Catheter Indications and Alternatives Facilitator Notes (doc file)
     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

294. Mod01-Grand-Rounds-Slides (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
     April 01, 2016 - Say: Today’s Presentation Goals are to: ■ Highlight the gap between optimal response to medical injury … the CANDOR process and how this toolkit will help organizations improve their response to medical injury … nursing staff in the room had Michelle connected to a monitor and monitored her heart rate, blood pressure … of ergonomics; as we work more at desks and computers, these areas are redesigned to help prevent injuries … Slide 35 Say: In addition to the organization Medically Induced Trauma Support Services (or MITSS)

295. Grand Rounds Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/grand-rounds.html
     August 01, 2022 - Say: Today's Presentation Goals are to: Highlight the gap between optimal response to medical injury … The nursing staff in the room had Michelle connected to a monitor and monitored her heart rate, blood pressure … Slide 12 Say: The response to medical injury involves more than just what to do and what … field of ergonomics; as we work more at desks and computers, these areas are redesigned to help prevent injuries … Slide 35 Say: In addition to the organization Medically Induced Trauma Support Services

296. Chartbook on Black Health Care: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/chartbooks/blackhealth/qdr-blackhealth-slides.html
     November 01, 2020 - Infant mortality per 1,000 live births (more than 2,499 grams) Worse No Change Birth trauma—injury … Slide 75 Birth trauma—injury to neonate per 1,000 live births, by race/ethnicity, 2004-2013 Image … : Chart shows birth trauma—injury to neonate per 1,000 live births, by race/ethnicity, 2004-2013: … Trends: From 2004 to 2013, birth trauma-neonatal injury rates fell from 2.6 per 1,000 live births … Between 2004 and 2012, birth trauma-neonatal injury rates fell for all racial/ethnic groups.

297. Resources by Safety Topic | Agency for Healthcare Research and Quality
     www.ahrq.gov/action-alliance/resources/type-harm.html
     July 01, 2025 - Falls Healthcare-Associated Infections Maternal Safety Medication Safety Never Events Opioid Safety Pressure … Center for Disease Control and Prevention (CDC) Stopping Elderly Accidents, Deaths & Injuries (STEADI … Back to Contents Pressure Ulcers AHRQ Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving … Quality of Care This resource assists hospital staff in implementing effective pressure ulcer prevention

298. Making It Work Tip Sheet: Multidisciplinary Rounding for Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/multidiscplinary-rounding.pdf
     April 01, 2022 - – healthcare-associated infection prevention efforts • Performance improvement specialist – safety, pressure … injury, and falls concerns • Social worker – discharge planning • Family members/patient – may be included

299. Table 13F: HCBS Population Ages 18-64 Without I/DD or SMI | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab13f.html
     December 01, 2012 - Composite: ACSC Overall 25,088 21,726 18,033 23,910 21,388 17,059 17,977 25,619 Pressure

300. Table 13C: Medicaid-Only HCBS Participants | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab13c.html
     December 01, 2012 - Composite: ACSC Overall 16,190 13,777 11,837 15,406 12,890 12,089 11,728 15,849 Pressure