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361. Appendix B1: The FMP Self-Assessment Tool (Text Description) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb1txt.html
     December 01, 2017 - Monthly falls analysis by: location and time of fall shift and day of week type of injury … Monthly falls analysis by # of falls, fallers, patients ≥2 falls, and falls with serious injury?   … of falls high-risk medications, sleep hygiene measures for management of anxiety low blood pressure … care plan include general behavior management strategies and specific interventions to reduce risk of injury … results of fall (BP, BS, mental status, VS, tests ordered, ER or hospital visit) description of injury

362. Spotlight
     psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_mismanagement_of_acute_decompensated_heart_failure_slides_final.pptx
     January 01, 2024 - hypervolemia, leading to mismanagement of her hypertensive emergency, irreversible progression of cardiac injury … to the ED.1 12 12 Background (4) 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

363. Table 16A: Outcome Indicators by County Socioeconomic Status | Agency for Healthcare Research and Quality
     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

364. Patient Safety and Adverse Events, 2011 and 2014 (pdf file)
     hcup-us.ahrq.gov/reports/statbriefs/sb237-Patient-Safety-Adverse-Events-2011-2014.pdf
     January 01, 2014 - The PSIs focus on adverse events during the hospital stay (such as pressure ulcers), complications associated … Ulcer Rate Wounds caused by unrelieved pressure on the skin usually around bony prominences PSI … to the body’s tissues and organs following an elective surgery PSI 14 Postoperative Wound Dehiscence … requiring dialysis (70.8 percent), postoperative wound dehiscence (70.3 percent), pressure ulcers … The 10 risk-adjusted rates contributing to PSI 90 are as follows:  Pressure Ulcer Rate (PSI 03) 

365. Supporting Clinicians to Improve Decision Making and Patients’ Care - Emerging Research | Digital Healthcare Research
     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

366. Exhibit 2.4 Average Length of Stay and Average Charges
     hcup-us.ahrq.gov/reports/factsandfigures/figures/2005/2005_2_4.jsp
     January 01, 2005 - 192 Umbilical cord complication 216.7 8.676 2.0 0.014890 7,100 175 193 Trauma … complications following abortion) 2.7 0.175 2.6 0.110958 12,800 831 235 Open wounds … examination/evaluation 16.7 4.161 * * * * 98 Essential hypertension (high blood pressure … 246 Fever of unknown origin 86.4 4.815 3.4 0.073659 13,300 507 244 Other injuries … during pregnancy) 220.3 8.652 3.5 0.043953 12,000 324 236 Open wounds of extremities

367. Report on the ISPE Drug Shortages Survey. | PSNet
     psnet.ahrq.gov/issue/report-ispe-drug-shortages-survey
     January 26, 2022 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

368. Eliminating vincristine administration events. | PSNet
     psnet.ahrq.gov/issue/eliminating-vincristine-administration-events
     February 15, 2023 - October 10, 2018 Early identification and evaluation of severe pressure injuries.

369. Indwelling Urinary Catheter Indications
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-indications.pptx
     April 01, 2022 - Knight is a 25-year-old man who was admitted with acute urinary retention, due to spinal injury. … when no or little urine is seen in bladder Consider urology consultation for prostatitis and urethral trauma … Closed pressure ulcers: stage I, deep tissue injury No No, unless has chronic ISC needs Yes, if the patient … require an indwelling urinary catheter if the wound can be kept clean by other methods Use alternatives … J Wound Ostomy Continence Nurs. 2020;47(6):601-18. PMID: 33201147.

370. Statistical Brief #3
     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

371. How can interventions more directly address drivers of unprofessional behaviour between healthcare staff? | PSNet
     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.

372. Patient safety in palliative care at the end of life from the perspective of complex thinking. | PSNet
     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 .

373. Long-term Care and Patient Safety | PSNet
     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).

374. Recommendation: Falls Prevention in Community-Dwelling Older Adults: Interventions | United States Preventive Services Taskforce
     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

375. Psn-Pdf (pdf file)
     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

376. Airway Obstruction during Anterior Cervical Spine Surgery | PSNet
     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.

377. C1 Prioritization Worksheet (pdf file)
     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

378. How safety is compromised when hospital equipment is a poor fit for patients who are obese. | PSNet
     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).

379. Psn-Pdf (pdf file)
     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

380. The Emergency Department & Catheter Insertions | Agency for Healthcare Research and Quality
     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