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41. Intramuscular Injections – Best Practices for Safe Vaccine Administration in Nursing Homes (pdf file)
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/intramuscular-injections.pdf
    June 01, 2021 - intramuscular (IM) administration is important to make sure the vaccine does its job and to avoid shoulder injury … and Health Administration (OSHA) regulations do not require you to wear gloves unless you have open wounds … Apply gentle pressure to the injection site for several seconds or longer to minimize bleeding using … For residents who take anticoagulation medications, gentle pressure may need to be applied longer to … pre-filled autoinjector (at least three doses) • H1 antihistamine (e.g., diphenhydramine/Benadryl) • Blood pressure

42. Overuse of Computed Tomography Scans for the Evaluation of Children with Atraumatic Headache: Technical Specifications (pdf file)
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0206-technicalspecs.pdf
    May 01, 2016 - Exclusions • Denominator/Numerator Exclusions o Trauma-related headache or pain (Table … IMG3) on the day of or within 7 days prior to imaging o Head trauma or suspected abuse/neglect (Table … 339.43 Other complicated 339.44 OTHER Post- traumatic headache 339.2x Acute pain due to trauma … excision of foreign body from brain 61570 Craniectomy or craniotomy; with treatment of penetrating wound … 852.x Other/unspecified intracranial hemorrhage following injury 853.x Intracranial injury of other

43. Health Care Facility Design Safety Risk Assessment Toolkit | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/hospital/resource/safety-assess.html
    October 01, 2020 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … The toolkit: Targets six areas of safety—infections, falls, medication errors, security, injuries of

44. 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/hai/pfp/hacrate2013.html
    January 01, 2018 - 2 In 2010 an HHS Office of the Inspector General (OIG) team identified the rate of harm—that is, injuries … The estimate for deaths associated with pressure ulcers was based primarily on the paper by Zhan and … Zhan and Miller estimated that excess mortality due to pressure ulcers was 72 deaths per 1,000 pressure … This estimate is based on analysis of data from HCUP identifying injuries in 7.45 million hospital discharge … For example, pressure ulcers had a high baseline prevalence, and excess mortality attributed to pressure

45. Declines in Hospital-Acquired Conditions | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/data/infographics/hac-rates_2019.html
    July 01, 2020 - Description: National efforts to reduce hospital-acquired conditions such as adverse drug events and injuries … Pressure ulcers: 6% increase. Surgical site infections: 8% increase.

46. C1 Prioritization Matrix (xls file)
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.xlsx
    July 01, 2016 - Patient Safety PSI 03 Pressure Ulcer   1.2 1.3 7 $109,870 $ 769,087 N 6 7 7 Y Y Y Y Y PSI 06 Iatrogenic … 13 Postoperative Sepsis 12.7 11.7 15 $49,215 $ 738,225 N 9 7 3 Y Y Y Y Y PSI 14 Postoperative Wound … Accidental Puncture or Laceration 3.2 3.3 1 $22,629 $ 22,629 Y 4 3 7 Y N Y Y Y Obstetric PSI 17 Birth Trauma-Injury … to Neonate   0.0 0.1 0 $88,000 $ - 0 N 2 3 9 Y Y Y Y Y PSI 18 Obstetric Trauma-Vaginal Delivery … Postoperative Sepsis Rate 0.0 16.2 0 $117,815 $ - 0 N 9 10 10 Y Y Y Y Y PDI 11 Postoperative Wound

47. Long-term Care Resources | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/long-term-care/resource/index.html
    November 01, 2021 - Effectiveness Reviews Facilities Home and Community Resources Findings Report Injuries … Nursing Homes: On-Time Prevention End of Life Care Home and Community-based Services Falls and Injury … Long-Term Care Facilities Multiple Chronic Conditions Omissions of Care in Nursing Homes Pressure

48. AHRQ's Quality & Patient Safety Programs by Setting: Long-Term Care | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/long-term-care/index.html
    September 01, 2021 - Effectiveness Reviews Facilities Home and Community Resources Findings Report Injuries … Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention is a team training curriculum to … help nursing homes with electronic medical records reduce the occurrence of pressure ulcers.

49. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
    May 17, 2016 - o Decreased central nervous system input (head injury, ingestion of central nervous system depressant … o Peripheral nerve/neuromuscular junction (spinal cord injury, organophosphate/carbamate poisoning, … expansion exercises with children, such as incentive spirometry, deep breathing, intermittent positive-pressure … breathing, and continuous positive airway pressure. … Noninvasive positive pressure ventilation for acute respiratory failure in children: a concise review

50. Module 1: Preventing Falls in Hospitals—Training Guide | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-1/guide.html
    September 01, 2017 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … Between 30 and 51 percent of falls in hospitals result in an injury ranging from bruises to severe wounds … The cost of serious fall-related injuries at three Midwestern hospitals. … Thus, the CAUTI, SSI, and Pressure Injury committees used the AHRQ assessment tools, and a speak-up campaign

51. Hospitals and Health Systems | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/hospital/resource/index.html
    August 01, 2022 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … Patients with Limited English Proficiency NICU Toolkit Preventing Falls in Hospitals Preventing Pressure

52. Fall TIPS: A Patient-Centered Fall Prevention Toolkit | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/hospital/fall-tips/index.html
    February 01, 2021 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … Background Falls are the most common cause of preventable injury.

53. AHRQ Quality Indicators Prioritization Worksheet Example (pdf file)
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.pdf
    June 29, 2016 - Postoperative Sepsis 12.7 11.7 15 $49,215 $ 738,225 N 9 7 3 Y Y Y Y Y PSI 14 Postoperative Wound … - Injury to Neonate 0.0 0.1 0 $88,000 $ - N 2 3 9 Y Y Y Y Y PSI 18 Obstetric … Trauma-Vaginal Delivery With Instrument 134.8 135.1 17 $90,000 $ 1,530,000 N 2 3 8 Y Y … Y Y Y PSI 19 Obstetric Trauma-Vaginal Delivery Without Instrument 17.0 17.9 5 $96,000 $ … Rate 0.0 16.2 0 $117,815 $ - N 9 10 10 Y Y Y Y Y PDI 11 Postoperative Wound

54. Data Infographics | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/data/infographics/index.html
    March 01, 2024 - Antidepressant Prescriptions Potentially Preventable Pediatric Hospital Stays Most Common Cause of Injuries … People Who Spent the Most for Healthcare in 2017 Causes of Hospital Stays for Traumatic Brain Injury … in 2017 High Healthcare Spending in 2017 Sports-Related Traumatic Brain Injuries Among Children … Hemodialysis Patients Worse Among Blacks HRSA's Health Center Program Making Progress on Blood Pressure

55. SOPS Nursing Home Survey: What You Need To Know - Nicholas Castle, Ph.D., M.H.A., FGSA (pdf file)
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-nh_webcast-castle.pdf
    January 01, 2006 - Hospitals ►Moving, Transferring, or Lifting Residents ►Medication errors ►Falls ►Pressure ulcers ►Sanitation … Patient Safety Culture in Nursing Homes • Safety culture influences staff as well as residents ► Overall injury

56. Case Scenarios: Handling Challenging Communications | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/scenarios.html
    August 01, 2022 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … 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

57. Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/research/findings/studies/index.html?page=484
    January 01, 2024 - (132) Blood Thinners (79) Brain Injury (64) Breast Feeding (18) Burnout (64) Cancer … (255) Imaging (245) Implementation (191) Infectious Diseases (260) Influenza (41) Injuries … and Wounds (207) Inpatient Care (221) Intensive Care Unit (ICU) (267) Kidney Disease and … Tools & Toolkits (49) Training (143) Transitions of Care (192) Transplantation (141) Trauma … Adv Skin Wound Care 2013 Feb;26(2):83-92; quiz p.93-4. doi: 10.1097/01.ASW.0000426718.59326.bb. .

58. B3A Combo Chartsforpresentations (xls file)
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b3a_combo_chartsforpresentations.xlsx
    January 01, 2006 - 0.1493487343 PSI 12 Statistically Lower 0 PSI 13 Postoperative sepsis 17.433 0 PSI 14 Postoperative wound … 0.0683602771 PSI 15 Statistically Lower 0 PSI 16 Transfusion reaction 0.000004 0 PSI 17 Birth trauma … - injury to neonate 2.188 0 PSI 18 Obstetric trauma - vaginal with instrument 0.139241 0.062898 … 0.215583 133.928 -99.8960329431 0.0570030165 0.0570022699 PSI 18 Statistically Lower 0 PSI 19 Obstetric trauma … 0.01989 -100 -100 117.3881347411 PDI 10 No Statistically Significant Difference 0 PDI 11 Postoperative Wound

59. Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/research/findings/studies/index.html?page=485
    January 01, 2024 - Autism (31) Back Health and Pain (58) Behavioral Health (699) Blood Clots (62) Blood Pressure … (132) Blood Thinners (79) Brain Injury (64) Breast Feeding (18) Burnout (64) Cancer … (255) Imaging (245) Implementation (191) Infectious Diseases (260) Influenza (41) Injuries … and Wounds (207) Inpatient Care (221) Intensive Care Unit (ICU) (267) Kidney Disease and … Tools & Toolkits (49) Training (143) Transitions of Care (192) Transplantation (141) Trauma

60. Appropriate Disclosure to a Patient: Video | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/hospital/candor/videos/app-disclosure.html
    August 01, 2022 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI