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61. Pediatric Toolkit for Using the AHRQ Quality Indicators | Agency for Healthcare Research and Quality
    preventiveservices.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

62. Communication: Severe Hypertension (pdf file)
    preventiveservices.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_3-communication-speaker-notes.pdf
    July 01, 2023 - patient's family members. 4 Hospital AIM Team Leads SPPC‐II Maternal and Perinatal Deaths and Injuries … communication breakdowns are identified as the primary root cause of maternal and perinatal deaths and injuries … Other root causes for maternal and perinatal deaths and injuries are— • Assessment (i.e., the adequacy … Severe‐range blood pressure was sustained for nearly an hour. Ms. … Untitled Communication Severe Hypertension Communication is… Maternal and Perinatal Deaths and Injuries

63. NPSD Dashboards | Agency for Healthcare Research and Quality
    preventiveservices.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.

64. Data Infographics | Agency for Healthcare Research and Quality
    preventiveservices.ahrq.gov/data/infographics/index.html
    March 01, 2024 - Antidepressant Prescriptions Potentially Preventable Pediatric Hospital Stays Most Common Cause of Injuries … People Who Spent the Most for Healthcare in 2017 Causes of Hospital Stays for Traumatic Brain Injury … in 2017 High Healthcare Spending in 2017 Sports-Related Traumatic Brain Injuries Among Children … Hemodialysis Patients Worse Among Blacks HRSA's Health Center Program Making Progress on Blood Pressure

65. Acknowledgments | Agency for Healthcare Research and Quality
    preventiveservices.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

66. Module 1: Preventing Falls in Hospitals—Slide Presentation | Agency for Healthcare Research and Quality
    preventiveservices.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.

67. Toolkit for Using the AHRQ Quality Indicators - A “How to” Guide for Improving Hospital Quality and Safety | Agency for Healthcare Research and Quality
    preventiveservices.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

68. Tennessee Hospital Association Uses AHRQ Tools To Boost Patient Safety, Saving $17 Million | Agency for Healthcare Research and Quality
    preventiveservices.ahrq.gov/news/newsroom/case-studies/201702.html
    March 01, 2017 - Injuries from falls and immobility. Obstetrical adverse events. Pressure ulcers. … Improvements in 2014 resulted in an estimated 45 percent reduction in pressure ulcers, 24 percent reduction

69. Communication: Severe Hypertension - PowerPoint Presentation
    preventiveservices.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_3_communication.pptx
    July 01, 2023 - interruption to a doctor who is with a patient's family members. 2 Maternal and Perinatal Deaths and Injuries … communication breakdowns are identified as the primary root cause of maternal and perinatal deaths and injuries … Other root causes for maternal and perinatal deaths and injuries are— Assessment (i.e., the adequacy, … Smith so you can treat her severe blood pressure and draw labs.  … Smith, you do not have severe-range blood pressure at this time. 

70. TeamSTEPPS® Instructor Manual: Specialty Scenarios | Agency for Healthcare Research and Quality
    preventiveservices.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

71. Home Mechanical Ventilators: Protocol Appendix A (pdf file)
    preventiveservices.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*"

72. AHRQ's Quality & Patient Safety Programs by Setting: Long-Term Care | Agency for Healthcare Research and Quality
    preventiveservices.ahrq.gov/patient-safety/settings/long-term-care/index.html
    September 01, 2021 - Effectiveness Reviews Facilities Home and Community Resources Findings Report Injuries … Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention is a team training curriculum to … help nursing homes with electronic medical records reduce the occurrence of pressure ulcers.

73. Methods To Estimate the Baseline 2010 PFP National Hospital-Acquired Condition Rate | Agency for Healthcare Research and Quality
    preventiveservices.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

74. How CMS Measures the "30-Day All Cause Rehospitalization Rate" on the Hospital Compare Web Site | Agency for Healthcare Research and Quality
    preventiveservices.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool-30day.html
    March 01, 2013 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

75. AHRQ National Scorecard on Hospital-Acquired Conditions: Updated Baseline Rates and Preliminary Results 2014-2016 (pdf file)
    preventiveservices.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

76. Module 1: Preventing Falls in Hospitals (doc file)
    preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module1/module1_fall-prevention.docx
    March 01, 2013 - In one study, a fall with serious injury added 6.3 days to the hospital stay. … The average operational cost for a fall with injury is about $14,000. … Between 30 and 51 percent of falls in hospitals result in an injury ranging from bruises to severe wounds … The cost of serious fall-related injuries at three Midwestern hospitals. … Thus, the CAUTI, SSI, and Pressure Injury committees used the AHRQ assessment tools, and a speak-up campaign

77. Declines in Hospital-Acquired Conditions | Agency for Healthcare Research and Quality
    preventiveservices.ahrq.gov/data/infographics/hac-rates_2019.html
    July 01, 2020 - Description: National efforts to reduce hospital-acquired conditions such as adverse drug events and injuries … Pressure ulcers: 6% increase. Surgical site infections: 8% increase.

78. Module 3: Best Practices in Fall Prevention—Slide Presentation | Agency for Healthcare Research and Quality
    preventiveservices.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.

79. Module 3: Best Practices in Fall Prevention—Training Guide | Agency for Healthcare Research and Quality
    preventiveservices.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.

80. Multiple Chronic Conditions Chartbook (pdf file)
    preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/mcc/mccchartbook.pdf
    April 01, 2014 - -4 NO YES 861 HEART & LUNG INJURY -5 NO -4 NO 863 GI TRACT INJURY -4 NO -3 NO 864 LIVER INJURY - … 3 NO -3 NO 869 INTERNAL INJURY NOS -3 NO -3 NO 871 EYEBALL OPEN WOUND -3 NO -4 NO 872 OPEN WOUND OF … OPEN WOUND OF LOWER ARM -5 NO -5 NO 882 OPEN WOUND OF HAND -5 NO -5 NO 883 OPEN WOUND OF FINGER -5 … 893 OPEN WOUND OF TOE -5 NO -5 NO 904 BLOOD VESSEL INJURY NEC -5 NO -4 NO 908 LATE EFF INJURY NEC … TO NERVE NEC/NOS -4 NO -4 NO 958 EARLY COMPLIC OF TRAUMA -4 NO -3 NO 959 INJURY NEC/NOS -4 NO -3 NO