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181. 2023 National Healthcare Quality and Disparities Report Appendixes (pdf file)
     cahps.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023-NHQDR-appendixes-ACDE-rev.pdf
     January 01, 2023 - 1,000 elective-surgery admissions, age 18 and over HCUP 2020 Reclosure of postoperative abdominal wound … 2020 Home health care patients whose management of oral medications improved OASIS 2021 Birth trauma … stages 2-4 pressure ulcer or unstageable pressure ulcer MDS 2021 Low-risk, long-stay nursing home … 2020 Home health care patients whose management of oral medications improved OASIS 2021 Birth trauma … stages 2-4 pressure ulcer or unstageable pressure ulcer MDS 2021 Low-risk, long-stay nursing home

182. Module 2: How To Manage Change (doc file)
     cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module2/module2_fall-prevention.docx
     August 24, 2017 - applied to other quality improvement efforts in a hospital, such as preventing: Hospital-acquired pressure … injuries.

183. Universal ICU Decolonization: An Enhanced Protocol (pdf file)
     cahps.ahrq.gov/sites/default/files/publications/files/universalicu.pdf
     September 01, 2013 - Wound Care 1. For what types of wounds is chlorhexidine (CHG) application safe? … to avoid causing additional soft tissue damage or extension of the wound due to pressure against the … #2: Nasal Trauma  Do NOT use mupirocin if nostril(s) are packed. …  CHG will not harm occlusive dressing (e.g., wound vacs).  Do NOT use on large or deep wounds … CHG can cause permanent injury if it comes in direct contact with nerves and is allowed to remain there

184. 2017Qdr-Patsafchartbook (pdf file)
     cahps.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/2017qdr-patsafchartbook.pdf
     October 01, 2018 - per 1,000 instrument-assisted deliveries • Birth trauma - injury to neonate per 1,000 selected live … 40 60 80 100 2014 2015 2016 2017 2018 2019 GOAL Ra te p er 1 ,0 00 D is ch ar ge s Pressure … 40 60 80 100 2014 2015 2016 2017 2018 2019 GOAL Ra te p er 1 ,0 00 D is ch ar ge s Pressure … Adverse Drug Events • An adverse drug event (ADE) is an injury—including physical harm, mental harm, … The home health team should regularly change wound dressing and teach the patient about wound care.

185. Fall Prevention Toolkit (doc file)
     cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module2/module2_tools.docx
     November 16, 2011 - Monthly falls analysis by: location and time of fall shift and day of week type of injury … consequences of falls High-risk medications, sleep hygiene measures for management of anxiety Low blood pressure

186. Catheter Ablation for Atrial Fibrillation: Topic Refinement - Project ID: CRDT0913 (pdf file)
     cahps.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/afib_topicref.pdf
     January 01, 2020 - peripheral vascular complication [including pseudoaneurysm, hematoma at catheter insertion site, vascular injury

187. Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals (pdf file)
     cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/lepguide/lepguide.pdf
     September 01, 2012 - 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 … Teamwork training improves the clinical care of trauma patients. … About 30 minutes later, he begins to develop some chest pressure, which he had not noticed before.

188. 2019 National Healthcare Quality and Disparities Report Data Sources (pdf file)
     cahps.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr-datasources.pdf
     December 01, 2020 - state-specific data on preventive health practices and risk behaviors linked to chronic diseases, injuries … The examination includes physical measurements, such as blood pressure and dental examinations, and … from each family in the house and collects data on topics including health status and limitations, injuries … infections; seven types of adverse events associated with surgery; patient falls; and hospital-acquired pressure … events associated with the hospital stay and not present on hospital admission (inpatient falls and pressure

189. Return on Investment Tool (doc file)
     cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/f1_combo_returnoninvestment.docx
     January 01, 2013 - For example, improvement actions might reduce hospital-associated infections, rates of pressure ulcers … Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization

190. Return on Investment Tool (pdf file)
     cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/f1_combo_returnoninvestment.pdf
     January 01, 2013 - For example, improvement actions might reduce hospital-associated infections, rates of pressure ulcers … Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization

191. 2023 National Healthcare Quality and Disparities Report Data Sources (pdf file)
     cahps.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023qdr-data-sources.pdf
     December 01, 2023 - state-specific data on preventive health practices and risk behaviors that are linked to chronic diseases, injuries … from each family in the house and collects data on topics including health status and limitations, injuries … patient’s age, gender, race, and ethnicity; patient’s expressed reason for visit; intentionality of injury … include mode of arrival, waiting time, duration of time in the ED, initial vital signs, and cause of injury … ulcer adverse events Pressure Ulcer Venous thromboembolism/pulmonary embolism (VTE/PE) not related

192. 2022 National Healthcare Quality and Disparities Report Data Sources (pdf file)
     cahps.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2022qdr-datasources.pdf
     December 01, 2022 - state-specific data on preventive health practices and risk behaviors linked to chronic diseases, injuries … The examination includes physical measurements, such as blood pressure and dental examinations, and … from each family in the house and collects data on topics including health status and limitations, injuries … patient’s age, gender, race, and ethnicity; patient’s expressed reason for visit; intentionality of injury … ulcer adverse events Pressure Ulcer Venous thromboembolism/pulmonary embolism (VTE/PE) not related

193. AHRQ Safety Program for Perinatal Care: Experiences from the Frontline (pdf file)
     cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_fullcolor.pdf
     May 01, 2017 - Root cause analyses of adverse events and near-misses (events that did not produce patient injury) … The AHRQ Patient Safety Indicator 18 (Obstetric Trauma–Vaginal Delivery with Instrument) decreased … in-house neonatal death, uterine rupture during labor, unplanned maternal admission to ICU, birth trauma … processes at the point of care to include specific maternal parameters, including blood loss, blood pressure … They established a standard process for blood pressure measurement upon admission and during labor

194. Final Progress Report: APPLIED STRATEGIES FOR IMPROVING PATIENT SAFETY (ASIPS) (pdf file)
     cahps.ahrq.gov/sites/default/files/2024-02/pace-report.pdf
     January 01, 2024 - to using the ASIPS reporting system included time, understanding what to report, and the constant pressures … Participants were recruited from a statewide post- injury program run by an ASIPS collaborator (COPIC … Two types of trauma (physical and emotional) were expected and found. … collaboratively helped both patients and providers with patients’ emotional, physical, and financial trauma

195. Making Informed Consent an Informed Choice: Training for Health Care Professionals Audio Script | Agency for Healthcare Research and Quality
     cahps.ahrq.gov/health-literacy/professional-training/informed-choice/audio-script.html
     September 01, 2020 - The final challenge is the time pressure we all face. … Some goals may be long-term, such as reducing the risk of future injury or illness, or living as long … Mom: I don't think I could forgive myself if he wound up dying of meningitis because we didn't finish … Non-invasive routine care, such as taking blood pressure, is usually covered by the blanket consent form

196. Making Informed Consent an Informed Choice: (pdf file)
     cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/audio-script-healthcare-professionals-training.pdf
     January 18, 2017 - The final challenge is the time pressure we all face. … Some goals may be long-term, such as reducing the risk of future injury or illness, or living as long … Mom: I don’t think I could forgive myself if he wound up dying of meningitis because we didn’t finish … Non-invasive routine care, such as taking blood pressure, is usually covered by the blanket consent

197. Hospital Survey on Patient Safety Culture: User's Guide (pdf file)
     cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/userguide/hospitalusersguide.pdf
     July 01, 2018 -  “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events … Whenever pressure builds up, my supervisor/manager wants us to work faster, even if it means taking shortcuts … Whenever pressure builds up, my supervisor/manager wants us to work faster, even if it means taking