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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
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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
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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.
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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
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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
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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.
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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
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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
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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.
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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
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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*"
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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.
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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
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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
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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
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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
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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.
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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.
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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.
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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