-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab16.html
December 01, 2012 - 9,257
6,892
Composite: ACSC Overall
17,570
24,934
20,620
17,662
23,518
18,337
Pressure … 10,435
7,884
Composite: ACSC Overall
19,406
27,524
22,656
19,821
25,958
20,278
Pressure … 5,382
4,110
Composite: ACSC Overall
12,450
16,541
14,919
11,150
15,491
12,897
Pressure … 3,777
3,248
Composite: ACSC Overall
5,094
6,963
6,484
4,695
6,310
5,297
Pressure … 8,215
6,780
Composite: ACSC Overall
17,579
23,121
20,378
17,055
21,295
18,297
Pressure
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digital.ahrq.gov/2020-year-review/research-summary/supporting-clinicians-improve-decision-making-and-patients-care-emerging-research
January 01, 2020 - patient care in hazardous decision-making environments fraught with excessive cognitive loading and time pressure … Hopkins University are investigating the use of AI to provide CDS in the detection of acute kidney injury … development and implementation of this AI-driven CDS system for detection and treatment of acute kidney injury … developed EHR-linked CDS tool, Peds & TeenBP, on screening and treatment of hypertension and high blood pressure … The research team aims to advance the standard practice of blood pressure measurement, increase hypertension
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psnet.ahrq.gov/issue/how-can-interventions-more-directly-address-drivers-unprofessional-behaviour-between
October 09, 2024 - December 19, 2018
Association of hospital participation in a regional trauma quality … Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.
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hcup-us.ahrq.gov/reports/statbriefs/sb3.jsp
April 01, 2006 - burden of hospitalizations related to pressure sores (figure 1). … The mean charge for hospital stays principally for pressures sores was $37,800, but charges varied by … paralysis, spinal cord injury, substance abuse, malnutrition, multiple sclerosis, stroke, and senility … percent), paralysis (27.4 percent), senility (22.7 percent), malnutrition (17.8 percent), spinal cord injury … Paralysis, spinal cord injury, and substance abuse were prominent among younger patients, while malnutrition
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psnet.ahrq.gov/issue/patient-safety-palliative-care-end-life-perspective-complex-thinking
October 05, 2022 - care can include inappropriate pain management , preventable hospital (re)admissions, falls, and pressure … injuries .
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psnet.ahrq.gov/primer/long-term-care-and-patient-safety
February 24, 2022 - care hospitals, including the ability to care for patients requiring mechanical ventilation, complex wound … Inpatient rehabilitation facilities (IRFs) care for patients recovering from surgery, trauma, or an … daily evaluation by a physician but do require services such as intensive nursing, physical therapy, or wound … injuries) during their stay, half of which were preventable. … injuries, and falls).
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psnet.ahrq.gov/issue/how-safety-compromised-when-hospital-equipment-poor-fit-patients-who-are-obese
October 07, 2020 - the identified events resulted in a delay in care and 41% resulted in temporary harm (e.g., falls, pressure … injuries, skin tears, abrasions).
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psnet.ahrq.gov/node/866343/psn-pdf
December 31, 2024 - hypervolemia, leading to mismanagement of her hypertensive emergency, irreversible progression of
cardiac injury … patients first present to the ED.1
The presence of pulmonary edema with hypoxemia and acute kidney injury … with an especially
elevated diastolic pressure. … nitroglycerin
(given that nitroprusside is relatively contraindicated in the setting of acute kidney injury … treating hypertensive emergencies, choosing appropriate antihypertensives for patients
with end-organ injury
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.pdf
June 02, 2025 - purchasing
• Sentinel
event
• Publicly
reported
• Public
perception
• Marketing
• Competitive
pressure … Rate on scale of 10 (agree/high) to 0 (disagree/low)
PSI 14 Postoperative
Wound … Dehiscence
PSI 15 Accidental
Puncture or Laceration
PSI 17 Birth Trauma-
Injury to Neonate
PSI … 18 Obstetric Trauma-
Vaginal Delivery With
Instrument
PSI 19 Obstetric Trauma-
Vaginal Delivery … 09 Postoperative
Respiratory Failure Rate
PDI 10 Postoperative
Sepsis Rate
PDI 11 Postoperative
Wound
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www.ahrq.gov/hai/cauti-tools/archived-webinars/ed-catheter-insertions-slides.html
December 01, 2017 - Few days later, he develops fever and his blood pressure drops. … Keeps patients from having to get up to urinate, protecting them from injury. … Trauma)
Admitting service (e.g. … Is the patient incontinent with open sacral or perineal wounds? … Protocolized care for trauma
Incontinence without open sacral or perineal wounds
Pre-operative
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psnet.ahrq.gov/node/867429/psn-pdf
December 18, 2024 - wound care and intravenous antibiotics. … Despite animal studies suggesting sealant alone can withstand high hydrostatic
pressures,52–54 some … Suture Choice in Lumbar Dural Closure Contributes to
Variation in Leak Pressures: Experimental Model … Quantification of leakage pressures after durotomy repairs
in the canine. … Occult spinal pseudomeningocele following a trivial injury
successfully treated with a lumboperitoneal
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psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
January 29, 2021 - His peak airway pressures were initially 23-25 cm H 2 O but suddenly increased to 48-52 about 30 minutes … Obesity is often associated with difficult ventilation because high airway pressures are required to … Thirty minutes into the operation the airway pressures suddenly increased from 25 to 50 cm of H 2 O and … Pneumothorax can occur in trauma patients who may have undiagnosed rib fractures. … Airway management in trauma.
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psnet.ahrq.gov/node/49725/psn-pdf
January 01, 2015 - Benefits include measurement of important parameters (e.g.,
PA occlusion wedge pressure [an indirect … indication of left atrial pressure, a surrogate for left ventricular
function], cardiac output, and … hurry-up" situation should be a red flag that leads to recognition of the
danger of such production pressures … While it is tempting to look at a case like this and focus only on understaffing or production pressures … Under all perioperative circumstances, but particularly with dangerously increased production
pressure
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/gW6MHsqzJ7Nn4a7S6S_9UN
June 04, 2024 - IMPORTANCE Falls are the leading cause of injury-related morbidity and mortality among
older adults in … (170 fall-related injuries per 1000 older adults). … disease events, cardiovascular disease mortality, and all-
cause mortality, as well as lower blood pressure … assessment using a com-
bination of various components, such as balance, gait, vision, pos-
tural blood pressure … initial assessment of modifiable risk factors for falls (eg, balance, gait, vision, postural
blood pressure
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digital.ahrq.gov/technology/fast-healthcare-interoperability-resources-fhir
January 08, 2025 - Study protocol: Collaboration Oriented Approach to Controlling High Blood Pressure … Study protocol: Collaboration Oriented Approach to Controlling High Blood Pressure (COACH) in adults … Project Name
Collaboration-Oriented Approach to Controlling High Blood Pressure (COACH) … clinical decision support to improve venous thromboembolism prophylaxis for patients with traumatic brain injury … clinical decision support to improve venous thromboembolism prophylaxis for patients with traumatic brain injury
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www.uspreventiveservicestaskforce.org/uspstf/recommendation/falls-prevention-community-dwelling-older-adults-interventions
June 04, 2024 - initial assessment of modifiable risk factors for falls (eg, balance, gait, vision, postural blood pressure … Falls are the leading cause of injury-related morbidity and mortality among older adults in the US. … adults 65 years or older reported at least 1 fall in the past year and 10.2% reported a fall-related injury … (170 fall-related injuries per 1000 older adults). … assessment using a combination of various components, such as balance, gait, vision, postural blood pressure
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www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/put5.html
October 01, 2014 - Remember, pressure ulcers are areas of soft tissue damage caused by pressure or pressure and shear. … If unsure whether it is a pressure ulcer, get help from the wound care nurse or another experienced clinician … Typically, this comprehensive evaluation is performed by an "outside" expert such as a wound nurse or … Therefore, consider performing a comprehensive skin assessment every 3 months with a wound care nurse … Pressure ulcers may take several days to develop after a severe pressure injury.
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/put5.html
October 01, 2014 - Remember, pressure ulcers are areas of soft tissue damage caused by pressure or pressure and shear. … If unsure whether it is a pressure ulcer, get help from the wound care nurse or another experienced clinician … Typically, this comprehensive evaluation is performed by an "outside" expert such as a wound nurse or … Therefore, consider performing a comprehensive skin assessment every 3 months with a wound care nurse … Pressure ulcers may take several days to develop after a severe pressure injury.
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psnet.ahrq.gov/issue/reducing-potential-errors-associated-insulin-administration-integrative-review
March 31, 2021 - March 31, 2021
Intervention study for the reduction of medication errors in elderly trauma … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.
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psnet.ahrq.gov/issue/decade-preventing-harm
July 10, 2008 - The health system sought to prevent pressure ulcers , adverse drug events , falls with injury , health … January 3, 2017
The cost of serious fall-related injuries at three midwestern hospitals