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pbrn.ahrq.gov/patient-safety/settings/hospital/candor/acknowledgements.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 … Sources include:
George Mason University
Harvard School of Public Health
Medically Induced Trauma
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pbrn.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursinghome-resourcelist.pdf
April 01, 2023 - Falls Management Program
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries … Provider Fax Report and Orders
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries … professionals/onthejob/falls.asp
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries … /fallspx/index.html
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspx … /fallspx/fallspxmanapb10pcp.html
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries
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pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.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
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pbrn.ahrq.gov/funding/grantee-profiles/grtprofile-catchpole.html
December 01, 2022 - From scrub techs failing to perform point-of-use reprocessing due to time pressures to limited space … and low lighting that resulted in fatigue and injuries, Dr. … Medication Delivery , focuses on reducing the 200,000 to 20 million anesthesia-related medication injuries … approaches, and perspectives across simulated and real environments to address these types of medication injuries
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pbrn.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
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pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apd.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
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pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apc.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
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pbrn.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.
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pbrn.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.
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pbrn.ahrq.gov/healthsystemsresearch/hspc-research-study/appendix-b.html
June 01, 2020 - Examples of intermediate outcomes include clinical health measures (e.g., adequate control of blood pressure … Intermediate outcomes include measures related to the incidence of chronic conditions—such as high blood pressure … This category includes studies of population health, injury occurrence, and disease progression. … Examples of intermediate outcomes of care are blood pressure, asthma, and glycemic control. … primarily examine how to treat injuries or disease (even if the injury or disease is preventable).
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pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5.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
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module1/module1_tools.docx
March 01, 2013 - bodies have definitions (e.g., the NQF defines a fall as “an unplanned descent to the floor without injury … study by van Gaal and colleagues evaluated a program that targeted three patient safety practices (pressure … and found an overall positive effect on the development of any adverse event, a composite measure of pressure … out specific fall assessments or interventions, and investigations such as lying and standing blood pressure … Violence and Injury Prevention: Falls. 2012.
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pbrn.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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pbrn.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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pbrn.ahrq.gov/teamstepps/instructor/scenarios/operroom.html
March 01, 2014 - At 2200, two emergency trauma cases arrive. … Comments
This scenario demonstrates how managing resources can prevent inefficiency or potential injury … chronic pain patient jumps from the hospital roof and sustains severe and multiple life-threatening injuries … The trauma surgeons request access to the Operating Room (OR) for immediate laparotomy and other repairs … Comments
This scenario demonstrates how cross-monitoring team members can help prevent error, damage, or injury
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pbrn.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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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/pfphac.pdf
September 01, 2014 - With Central 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 data … The national number of adverse events captured by PSIs 18 and 19 on obstetric injury, and the
national … Ulcers
Hospital-Acquired Pressure
Ulcers
53.03 62.45 0.85
VAP Ventilator-Associated
Pneumonia … Falls MPSMS In-Hospital Patient Falls 262,317 32,750,000 8.010
Obstetric
Adverse Events
PSI OB Trauma
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pbrn.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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pbrn.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/hmv-protocol-appendixa.pdf
October 11, 2017 - or NPPV or "Positive Airway Pressure*" or "positive end-
expiratory pressure*").ti.
25411
3 1 or … 5811
14 *Obesity/ 256788
15 *Respiratory Insufficiency/ 25610
16 *Scoliosis/ 20526
17 *Spinal Cord Injuries … ventilation" or "non-invasive positive pressure ventilation" or NPPV or "Positive Airway
Pressure*" … ventilation" or "non-invasive positive pressure ventilation" or NPPV or "Positive Airway
Pressure*" … ventilation" or "non-invasive positive pressure
ventilation" or NPPV or "Positive Airway Pressure*"
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pbrn.ahrq.gov/news/newsroom/ahrq-stats.html
November 01, 2023 - , by Cause of Injury, 2017 .) … Trauma During Childbirth
The rate of obstetric trauma during childbirth involving instruments such as … Decreasing Pressure Ulcers Among Hospital Patients
The average rate of hospital-associated pressure … Pressure Ulcer Rates of Hospital Patients
About 1.2 million cases of hospital-acquired pressure ulcers … highest average expenses per person were for the treatment of heart conditions ($3,794 per person), trauma-related