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  1. www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-fullreport.pdf
    April 01, 2018 - This measure calculates the rate of adverse events (patient harm)—defined as unintended physical injury … Black and Hispanic newborns are at higher risk of birth trauma (Miller, et al., 2003). … Although AEs most often result in transient harms, some lead to permanent injury and death. … : "Naloxone administration," “Health care- associated infections: positive C. difficile test,” and "Pressure … Internal pressures, such as a punitive culture that leads to underreporting of medical errors, may influence
  2. www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0230-fullreport.pdf
    April 02, 2018 - Unlike adults, the diagnosis of septic shock in children does not require the presence of low blood pressure … (hypotension), as children often maintain normal blood pressure until the advanced stages of shock … A limited window of opportunity exists for therapy of the underlying injury once shock is present. … Because children often maintain their blood pressure until they are severely ill, systemic hypotension … For severe sepsis, one abstractor indicated that there was a low systolic blood pressure despite the
  3. www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0231-fullreport.pdf
    May 01, 2018 - Unlike adults, the diagnosis of septic shock in children does not require the presence of low blood pressure … (hypotension), as children often maintain normal blood pressure until the advanced stages of shock … A limited window of opportunity exists for treating underlying injury once shock is present. … Because children often maintain their blood pressure until they are severely ill, systemic hypotension … For severe sepsis, one abstractor indicated that there was a low systolic blood pressure despite the
  4. www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc-resource_list.pdf
    March 01, 2016 - Staffing, Work Pressure, and Pace ................................ 4 Composite 4. … Effective Crisis Management Living a Culture of Patient Safety Policy and Brochure Medically Induced Trauma … Staffing, Work Pressure, and Pace 1. … portfolio aims to identify risks and hazards that lead to medical errors and find ways to prevent patient injury … Staffing, Work Pressure, and Pace Composite 4. Teamwork Composite 5. Staff Training Composite 6.
  5. www.healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
    August 01, 2022 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit PressureInjury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … The event review focuses on uncovering latent hazards or contributing factors that increase pressure
  6. www.healthcare411.ahrq.gov/ncepcr/research-transform-primary-care/transform/tpcbib/index.html
    May 01, 2015 - Hemoglobin A1c and blood pressure values in patients with diabetes were not significantly different between … The number of hospitalizations for unintentional injury and asthma also decreased after implementation … PMID: 23690385 The authors compared emergency care usage for any reason, asthma, and unintentional injury … As a comparison, emergency care use for unintentional injury had been increasing before and during implementation … Among patients with hypertension, frequent in-person visits were associated with better blood pressure
  7. www.healthcare411.ahrq.gov/ncepcr/reports/grants-transform/bibliography/index.html
    February 01, 2017 - Hemoglobin A1c and blood pressure values in patients with diabetes were not significantly different between … The number of hospitalizations for unintentional injury and asthma also decreased after implementation … PMID: 23690385 The authors compared emergency care usage for any reason, asthma, and unintentional injury … As a comparison, emergency care use for unintentional injury had been increasing before and during implementation … Among patients with hypertension, frequent in-person visits were associated with better blood pressure
  8. www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-228-fullreport.pdf
    February 01, 2018 - Unlike adults, the diagnosis of septic shock in children does not require the presence of low blood pressure … (hypotension), as children often maintain normal 6 blood pressure until the advanced stages of … A limited window of opportunity exists for treating underlying injury once shock is present. … Because children often maintain their blood pressure until they are severely ill, systemic hypotension … requirement for diagnosis of septic shock in children; in fact, shock may occur long before blood pressure
  9. www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/tpc/tpc-synthesis-report.pdf
    July 22, 2015 - post-implementation period.33 The trend applied to emergency care use overall and to asthma and unintentional injury … Specifically, the percent of PCMH patients hospitalized per month (overall and for asthma and unintentional injury … Donahue, MD, MPH Diabetes • HbA1c <9% • LDL cholesterol <100 mg/dL • Blood pressure <130/80 … ≤130/80 mm Hg • LDL cholesterol ≤100 mg/dL Cardiovascular disease: • Blood pressure ≤130/80 … Gabbay, MD, PhD Diabetes • HbA1c <7% • Blood pressure <130/80 mm Hg • LDL cholesterol <100
  10. www.healthcare411.ahrq.gov/patient-safety/reports/advancing/index.html
    July 01, 2022 - private-public partnerships to: (1) identify the causes of preventable health care errors and patient injury … By using hospital administrative data, PSIs can identify pressure ulcers, postoperative pulmonary emboli … Education in 2003 and that the long shifts medical interns worked led to 61 percent more needlestick injuries
  11. www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0197-fullreport.pdf
    November 01, 2019 - These complications include compromised airway, hypoxia leading to central nervous system injury, and … moderate and deep sedation carry 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 … , veins, or nerves; alterations in blood pressure; and/or irregular heart rhythms (Society for Pediatric
  12. www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023-NHQDR-appendixes-ACDE-rev.pdf
    January 01, 2023 - 1,000 elective-surgery admissions, age 18 and over HCUP 2020 Reclosure of postoperative abdominal wound … 2020 Home health care patients whose management of oral medications improved OASIS 2021 Birth trauma … stages 2-4 pressure ulcer or unstageable pressure ulcer MDS 2021 Low-risk, long-stay nursing home … 2020 Home health care patients whose management of oral medications improved OASIS 2021 Birth trauma … stages 2-4 pressure ulcer or unstageable pressure ulcer MDS 2021 Low-risk, long-stay nursing home
  13. www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/perinatal/chipra-0082-fullreport.pdf
    March 01, 2016 - delivery are at much higher risk for rehospitalization for uterine infection and obstetrical surgical wound … nonmedical factors such as provider density, the capacity of the local health care system, and malpractice pressure … o Have a physical abnormality or injury to their brain or spinal cord. … For example, there may be fewer surgical injuries and fewer infections. … vaginally is more likely to have a nerve injury that affects the shoulder, arm, or hand.
  14. www.healthcare411.ahrq.gov/news/events/nac/2017-11-nac/nacmtg1117-minutes.html
    February 01, 2018 - Preliminary data on the use of the training materials showed significant decreases in falls with injury … AHRQ also released training materials for preventing pressure ulcers in hospitals. … Preliminary data on use of the materials showed significant decreases in pressure ulcers during a 1-year
  15. www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module2/module2_tools.docx
    November 16, 2011 - Monthly falls analysis by: location and time of fall shift and day of week type of injury … consequences of falls High-risk medications, sleep hygiene measures for management of anxiety Low blood pressure
  16. www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/2017qdr-patsafchartbook.pdf
    October 01, 2018 - per 1,000 instrument-assisted deliveries • Birth trauma - injury to neonate per 1,000 selected live … 40 60 80 100 2014 2015 2016 2017 2018 2019 GOAL Ra te p er 1 ,0 00 D is ch ar ge s Pressure … 40 60 80 100 2014 2015 2016 2017 2018 2019 GOAL Ra te p er 1 ,0 00 D is ch ar ge s Pressure … Adverse Drug Events • An adverse drug event (ADE) is an injury—including physical harm, mental harm, … The home health team should regularly change wound dressing and teach the patient about wound care.
  17. www.healthcare411.ahrq.gov/sites/default/files/publications/files/lepguide.pdf
    September 01, 2012 - Adverse event*: Any injury caused by medical care. … include pneumothorax from central venous catheter placement, anaphylaxis to penicillin, postoperative wound … Similarly, postoperative wound infections count as adverse events even if the operation proceeded with … Teamwork training improves the clinical care of trauma patients. … About 30 minutes later, he begins to develop some chest pressure, which he had not noticed before.
  18. www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/afib_topicref.pdf
    January 01, 2020 - peripheral vascular complication [including pseudoaneurysm, hematoma at catheter insertion site, vascular injury
  19. www.healthcare411.ahrq.gov/health-literacy/professional-training/lepguide/exec-summary.html
    September 01, 2020 - not be harmed by the care that is intended to help them, and they should remain free from accidental injury … admissions and/or discharge. 68 Greater risk of line infections, surgical infections, falls, and pressure
  20. www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr-datasources.pdf
    December 01, 2020 - state-specific data on preventive health practices and risk behaviors linked to chronic diseases, injuries … The examination includes physical measurements, such as blood pressure and dental examinations, and … from each family in the house and collects data on topics including health status and limitations, injuries … infections; seven types of adverse events associated with surgery; patient falls; and hospital-acquired pressure … events associated with the hospital stay and not present on hospital admission (inpatient falls and pressure

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