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www.monahrq.ahrq.gov/npsd/data/dashboard/index.html
October 01, 2023 - to falls, the presence of fall assistance, presence of fall assistance by patient harm, type of fall injury … Pressure Ulcer Dashboard
Details the documentation of increased risk for pressure ulcer following a … risk assessment; and the timing of the first risk assessment for reported pressure ulcers or sDTIs.
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www.monahrq.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?
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www.monahrq.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
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www.monahrq.ahrq.gov/patient-safety/settings/hospital/candor/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
-
www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/natlhacratereport-rebaselining2014-2016_0.pdf
January 01, 2016 - patient safety events, including
many types of hospital-acquired infections, adverse drug events, and injuries … Ulcers/Pressure Injuries
Surgical Site Infections
Ventilator-Associated
Pneumonias
(Post-op) Venous … Central Venous Catheters
Falls MPSMS In-Hospital Patient Falls
Obstetric
Adverse
Events
PSI OB Trauma … National number of adverse events captured by PSIs 18 and 19 on obstetric
injury and national number … 8,513 0.29
Falls MPSMS In-Hospital Patient Falls 238,965 8.03
Obstetric
Adverse
Events
PSI OB Trauma
-
www.monahrq.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?
-
www.monahrq.ahrq.gov/hai/pfp/methods.html
December 01, 2017 - Venous Catheters
Falls
MPSMS
In-Hospital Patient Falls
Obstetric Adverse Events
PSI
OB Trauma … Pressure Ulcers
Surgical Site Infections
NHSN
SSIs combined for 17 procedures based on CDC NHSN … The national number of adverse events captured by PSIs 18 and 19 on obstetric injury , and the national … MPSMS
In-Hospital Patient Falls
262,317
32,750,000
8.010
Obstetric Adverse Events
PSI
OB Trauma … Ulcer
MPSMS
Hospital-Acquired Pressure Ulcers
1,317,211
32,750,000
40.220
Surgical Site
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www.monahrq.ahrq.gov/patient-safety/quality-measures/qsrs/index.html
September 01, 2022 - events, including certain hospital-acquired conditions (HACs), such as postsurgical complications and pressure … events, e.g., not just fall rates over a given time, but also the percentage of falls that resulted in injury … and the rates of each specific type of injury.
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www.monahrq.ahrq.gov/patient-safety/settings/hospital/resource/qitool/pediatric.html
December 01, 2017 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … Introduction PDF [ - 38.47 KB] PDI01 Accidental Puncture or Laceration PDF [ - 62.74 KB] PDI02 Pressure … Respiratory Failure PDF [ - 65.96 KB] PDI10 Postoperative Sepsis PDF [ - 112.29 KB] PDI11 Postoperative Wound
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www.monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules.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
-
www.monahrq.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0198-tables1-9.pdf
October 16, 2019 - 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
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www.monahrq.ahrq.gov/news/newsletters/e-newsletter/893.html
December 01, 2023 - The winners of the competition are:
University of Missouri Health Care utilized AHRQ’s Preventing Pressure … Ulcers in Hospitals: A Toolkit for Improving Quality of Care to decrease reportable pressure injuries
-
www.monahrq.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module5.pptx
January 01, 1995 - or unfolding error
An opportunity to interrupt or correct an action or event before there is harm or injury … It allows for one to take steps to interrupt or correct an action or event before there is harm or injury … Are the blood pressure cuffs, otoscope, and ophthalmoscopes working properly? … Are things being left undone because of time pressure?
-
www.monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apa.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
-
www.monahrq.ahrq.gov/patient-safety/settings/hospital/resource/qitool/webinar080116/index.html
December 01, 2017 - Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … Pulmonary Embolism or Deep Vein Thrombosis Rate *
PSI 13: Postoperative Sepsis *
PSI 14: Postoperative Wound … PSI 15: Unrecognized Abdominopelvic Accidental Puncture or Laceration *
PSI 18-‐19: Obstetric Trauma … PDI 09: Postoperative Respiratory Failure
PDI 10: Postoperative Sepsis
PDI 11: Postoperative Wound … Pressure Ulcer Risk Assessment at Admission and Daily: Evaluate all patients for pressure ulcers and
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www.monahrq.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-3/guide.html
September 01, 2017 - Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … Post-Fall Huddles: Reducing Preventable Falls and Fall-Related Injuries —AHRQ Fall Prevention Program … 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.
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www.monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes7.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 … Potential future injuries that may result from the adverse event.
-
www.monahrq.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-3/slides.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 … number of medications that could cause sedation, confusion, impaired balance, or orthostatic blood pressure … Carefully assess patients for any injuries in a systematic way.
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www.monahrq.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-1/slides.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 … Medicare won’t pay for increased costs due to injury from inpatient falls. … Falls harm patients.
30% to 51% of falls result in injury.
Many falls are preventable.
-
www.monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apb.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