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  1. www.monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes1.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
  2. www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module3/module3_fall-prevention.docx
    January 01, 2013 - Prevention Program Training Webinar Post-Fall Huddles: Reducing Preventable Falls and Fall-Related Injuries … medications or medicines that could cause sedation, confusion, impaired balance, or orthostatic blood pressure … The patient should be carefully and systematically assessed for injuries. … The post-fall clinical review focuses on immediate risk of injury or complications. … RCA is often used for a fall with injury.
  3. www.monahrq.ahrq.gov/patient-safety/settings/hospital/candor/impguide.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 … Medicine (IOM) report, To Err Is Human: Building a Safer Health System , the problems associated with injury
  4. www.monahrq.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/implement-fac-guide.html
    July 01, 2023 - Slide 6: Root Causes of Maternal and Perinatal Deaths and Injuries 2004-2012 Say: Human factors … 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. Leadership. … Example: The nurse says to the doctor, "Doctor, the patient's blood pressure is dropping; it is 60/
  5. www.monahrq.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-4/slides.html
    September 01, 2017 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit PressureInjury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI
  6. www.monahrq.ahrq.gov/health-literacy/professional-training/lepguide/chapter1.html
    September 01, 2020 - 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 … Near miss/close call * : An event or situation that did not produce patient injury, but only because … LEP patients are at greater risk of line infections, surgical infections, falls, and pressure ulcers
  7. www.monahrq.ahrq.gov/news/newsletters/e-newsletter/861.html
    April 01, 2023 - The COVID-19 pandemic has intensified these pressures. … J Trauma Acute Care Surg 2023 Apr;94(5):592-8. Epub 2023 Nov 18. … Renal outcomes following intravenous contrast administration in patients with acute kidney injury: a
  8. www.monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes2.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
  9. www.monahrq.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html
    June 01, 2022 - The Preventing Pressure Ulcers in Hospitals Toolkit assists hospital staff in implementing effective … pressure ulcer prevention practices through an interdisciplinary approach to care. … The toolkit draws on literature on best practices in pressure ulcer prevention and includes both validated … patients can suffer adverse outcomes and even fatal complications, and clinicians can be exposed to injury
  10. www.monahrq.ahrq.gov/challenges/data-visualization/index.html
    February 01, 2024 - higher prevalence of HIV in men who have sex with men), or socioeconomic factors (e.g., higher blood pressure … the Federal Government and its related entities, except in the case of willful misconduct, for any injury … whether direct, indirect, or consequential, arising from participation in this prize contest, whether the injury
  11. www.monahrq.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-4/guide.html
    October 01, 2017 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit PressureInjury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … Critical Thinking for Fall Injury Prevention —AHRQ Fall Prevention Program Implementation Sharing Webinar
  12. www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/implement/implement-facilitator-guide.docx
    May 01, 2017 - 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, Leadership, Information … Example: The nurse says to the doctor, “Doctor, the patient’s blood pressure is dropping; it is 60/40
  13. www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/ascwebinar/ascwebcast0715_transcript.pdf
    September 01, 2015 - our overall efforts in patient safety, and as part of the National Action Plan for health-associated injuries … Smith, Slide 23 And the area with the most room for improvement was Staffing, Work Pressure and Pace … Smith, Slide 25 The two bottom-performing items were from Staff Training and the Staffing, Work Pressure … And you can see that for Staffing, Work Pressure and Pace it was a 94 percent positive compared to a … Brown, Slide 44 Our second area of focus was Staffing, Work Pressure and Pace, and our result was 55
  14. www.monahrq.ahrq.gov/research/findings/making-healthcare-safer/comparison.html
    September 01, 2022 - Evidence (Not reviewed) (Not reviewed) Interventions To Prevent Contrast-Induced Acute Kidney Injury … Summary of Evidence Update (all patients) (Not reviewed) Preventing Patient Death or Serious Injury … Institutionalized Older People Summary of Evidence Update (all patients) (Not reviewed) Prevention of Pressure
  15. www.monahrq.ahrq.gov/news/blog/ahrqviews/defining-new-ahrq.html
    January 01, 2021 - HAC events amount to more than $28 billion in excess healthcare costs, including pressure ulcers ($9.9 … nurses and other healthcare professionals remains a significant and troubling issue, as do workplace injuries
  16. www.monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.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
  17. www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-comm-assessment.pdf
    April 01, 2016 - Eventually, they are able to re-establish a normal heart rate, blood pressure, and adequate blood oxygen … During her procedure, her heart rate, blood pressure, and oxygen level were monitored. … During a part of the procedure, we became aware that her heart rate, blood pressure, and oxygen level … First off, right now Mary is stable; her heart rate, blood pressure, and oxygen level are all in normal … We also don’t know right now if she has suffered any injury from what happened, but we will check her
  18. www.monahrq.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-192-fullreport.pdf
    November 01, 2019 - These complications include compromised airway, hypoxia leading to central nervous system injury, and … • Signs or symptoms of increased intracranial pressure (Table 10 [=IMG11]; see Supporting Documents … • Signs or symptoms of increased intracranial pressure. • Abnormal neurologic exam. … These risks include dental trauma; airway edema (swelling of the windpipe); vocal cord spasm or injury … Incidental findings in children with blunt head trauma evaluated with cranial CT scans.
  19. www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/implement/implement-facilitator-guide.pdf
    May 01, 2017 - 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, • Leadership, … Example: The nurse says to the doctor, “Doctor, the patient’s blood pressure is dropping; it is 60
  20. www.monahrq.ahrq.gov/health-literacy/professional-training/lepguide/app-b.html
    September 01, 2020 - About 30 minutes later, he begins to develop some chest pressure, which he had not noticed before. … prevented the severe allergic reaction and allowed him to receive the angioplasty that could have prevented injury

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