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101. AHRQ's Quality & Patient Safety Programs by Setting: Long-Term Care | Agency for Healthcare Research and Quality
     talkingquality.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.

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

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

104. Gap Analysis Facilitator's Guide: Appendix B | Agency for Healthcare Research and Quality
     talkingquality.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apb.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

105. Gap Analysis Facilitator's Guide: Appendix C | Agency for Healthcare Research and Quality
     talkingquality.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

106. Event Investigation and Analysis Guide: Appendix D | Agency for Healthcare Research and Quality
     talkingquality.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

107. Module 7: Resolution | Agency for Healthcare Research and Quality
     talkingquality.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.

108. Declines in Hospital-Acquired Conditions | Agency for Healthcare Research and Quality
     talkingquality.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.

109. Module 5: Situation Monitoring
     talkingquality.ahrq.gov/sites/default/files/wysiwyg/teamstepps/diagnosis-improvement/module5-situation-monitoring.pptx
     January 10, 2022 - It also ensures staff are supported in times of stress or production pressures or when the day is just … allows individuals and teams to take steps to interrupt or correct an action or event before harm or injury … risk or unfolding error An opportunity to interrupt or correct an action or event before harm or injury … Are the blood pressure cuffs, otoscope, ophthalmoscopes, and other equipment working properly? … Are things being left undone because of time pressure?

110. Module 1: Preventing Falls in Hospitals (doc file)
     talkingquality.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

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

112. Mod01-Grand-Rounds-Slides (pdf file)
     talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
     April 01, 2016 - Say: Today’s Presentation Goals are to: ■ Highlight the gap between optimal response to medical injury … the CANDOR process and how this toolkit will help organizations improve their response to medical injury … nursing staff in the room had Michelle connected to a monitor and monitored her heart rate, blood pressure … of ergonomics; as we work more at desks and computers, these areas are redesigned to help prevent injuries … Slide 35 Say: In addition to the organization Medically Induced Trauma Support Services (or MITSS)

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

114. PowerPoint Presentation
     talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
     January 01, 2014 - Video: Do Less Harm 2 Presentation Goals Highlight the gap between optimal response to medical injury … Resolution) process and how this toolkit will help organizations improve their response to medical injury … The nursing staff in the room had Michelle connected to a monitor and monitored her heart rate, blood pressure … field of ergonomics; as we work more at desks and computers, these areas are redesigned to help prevent injuries … helps them care for their patients. 36 Module 1 In addition to the organization Medically Induced Trauma

115. Communication Assessment Guide | Agency for Healthcare Research and Quality
     talkingquality.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

116. Module 3: Preparing for Implementation: Gap Analysis | Agency for Healthcare Research and Quality
     talkingquality.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/notes.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 … An adverse event is "any injury caused by medical care" and doesn't imply "error," "negligence," or poor

117. Gap Analysis Facilitator's Guide | Agency for Healthcare Research and Quality
     talkingquality.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3.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

118. Care for the Caregiver Program Implementation Guide | Agency for Healthcare Research and Quality
     talkingquality.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide6.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 … For additional support in the planning process, Medically Induced Trauma Support Services (MITSS) resources

119. Final Topic Refinement Document - Therapeutic Options for Obesity in the Medicare Population (pdf file)
     talkingquality.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/obesity_topic-refinement.pdf
     May 22, 2014 - Adverse effects of interventions ● Activity-related injury ● Adverse effects of medication ( diarrhea … Respiratory disease (i.e., asthma, COPD) ● Sleep apnea o BMI o Adverse effects ● Activity-related injuries … Question 1b CMS Intermediate outcomes We are excluding all intermediate outcomes (adherence, blood pressure … outcomes CMS Intermediate outcomes We are excluding all intermediate outcomes (adherence, blood pressure … skinfold thickness and waist circumference; excluding all intermediate outcomes (adherence, blood pressure

120. Re-Engineered Discharge (RED) Toolkit | Agency for Healthcare Research and Quality
     talkingquality.ahrq.gov/patient-safety/settings/hospital/red/toolkit/index.html
     April 01, 2023 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI