AHRQ Search | Home Page

AHRQ's Quality & Patient Safety Programs by Setting: Hospital | Agency for Healthcare Research and Quality

teamstepps.ahrq.gov/patient-safety/settings/hospital/index.html

March 01, 2024 - Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … pressure ulcer prevention practices through an interdisciplinary approach to care. … Pressure Injury Prevention in Hospitals Training Program supports the training of hospital staff on … how to implement AHRQ's Preventing Pressure Ulcers in Hospitals Toolkit. … injury prevention.

Introduction to the Quality Indicators Best Practices Tool (pdf file)

teamstepps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4_combo_bestpracticescover.pdf

June 05, 2016 - Best practices forms exist for the following 14 PSIs: • PSI 03 Pressure Ulcer Rate • PSI 05 Retained … Pulmonary Embolism or Deep Vein Thrombosis Rate • PSI 13 Postoperative Sepsis Rate • PSI 14 Postoperative Wound … 03 Neonatal Blood Stream Infection Rate • PDI 01 Accidental Puncture or Laceration Rate • PDI 02 Pressure … Postoperative Respiratory Failure Rate • PDI 10 Postoperative Sepsis Rate • PDI 11 Postoperative Wound … • PSI 17 Birth Trauma Rate―Injury to Neonate: The existing literature on birth trauma and injury

AHRQ National Scorecard on Hospital-Acquired Conditions: Updated Baseline Rates and Preliminary Results 2014-2017 (pdf file)

teamstepps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hacreport-2019.pdf

January 01, 2019 - due to procedures, as well as pressure ulcers/pressure injuries and falls. … ulcers/pressure injuries increased from 2014 to 2015 and then decreased somewhat from 2015 to 2016 … Ulcers/ Pressure Injuries 21.7 23.5 22.7 23.0 6% 17.4 Surgical Site Infections 2.5 2.5 2.5 … Pressure Ulcers/Pressure Injuries Surgical Site Infection NHSN SSIs for 17 procedures w/CDC SCIP … Ulcers/Pressure Injuries Surgical Site Infection NHSN SSIs for 17 procedures w/CDC SCIP+5

Agency for Healthcare Research and Quality

teamstepps.ahrq.gov/research/findings/studies/index.html?page=1

January 01, 2024 - and Wounds (207) Inpatient Care (220) Intensive Care Unit (ICU) (264) Kidney Disease and … Outcome measures included hypertension, systolic blood pressure >130 mmHG, and hyperglycemia. … center (NTC) and were diagnosed with a traumatic injury with an injury severity score of greater than … , major chest injury, and presentation at a teaching hospital. … , Injuries and Wounds Cron DC , Braun HJ , Ascher NL Sex-based disparities in access to

AHRQ’s Safety Program for Nursing Homes: On-Time Prevention | Agency for Healthcare Research and Quality

teamstepps.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/index.html

November 01, 2017 - Effectiveness Reviews Facilities Home and Community Resources Findings Report Injuries … Adverse Events Pressure Ulcer Prevention . Pressure Ulcer Healing .

Module 5: How To Measure Fall Rates and Fall Prevention Practices—Slide Presentation | Agency for Healthcare Research and Quality

teamstepps.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-5/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 … None or no injury: The patient is free of injuries (no signs or symptoms) resulting from a fall … Death: The patient died as a result of injuries sustained from the fall (not from physiologic events … Slide 13: NDNQI Definitions of Fall Injury None: No injury Minor: Resulted in bruise, abrasion

AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality

teamstepps.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/index.html

May 01, 2016 - Effectiveness Reviews Facilities Home and Community Resources Findings Report Injuries … Pressure ulcers remain a serious problem in nursing homes despite regulatory and market approaches to … Pressure ulcers cause pain, disfigurement, and increased infection risk and are associated with longer … Median annual nursing home pressure ulcer prevalence was 7.5 percent in 2009, with associated costs of … Materials Self-Assessment Worksheet for Pressure Ulcer Prevention .

Module 5: How To Measure Fall Rates and Fall Prevention Practices—Training Guide | Agency for Healthcare Research and Quality

teamstepps.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-5/guide.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 … injuries (no signs or symptoms) resulting from the fall. … treating with ice, cleaning the wound, limb elevation, topical medication, or a bruise or abrasion. … Interventions to prevent falls and fall injuries are tracked.

Documentation and Coding for Patient Safety Indicators (pdf file)

teamstepps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b4_combo_documentationcoding.pdf

March 15, 2016 - PDI 02 Pressure Ulcer Rate (stage III, IV, Unstageable) Diagnosis and site of pressure ulcer must … PSI 18, PSI 19 OB Trauma – Vaginal Delivery With Instrument OB Trauma – Vaginal Delivery Without … X PDI 11 Postoperative Wound Dehiscence Rate X Depth of the wound dehiscence: external/superficial … X PSI 14 Postoperative Wound Dehiscence X Depth of the wound dehiscence: external/superficial vs … PSI 18 PSI 19 OB Trauma – Vaginal Delivery With Instrument OB Trauma – Vaginal Delivery Without

Hospitals and Health Systems | Agency for Healthcare Research and Quality

teamstepps.ahrq.gov/patient-safety/settings/hospital/resource/index.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 … Patients with Limited English Proficiency NICU Toolkit Preventing Falls in Hospitals Preventing Pressure

C1 Prioritization Matrix (xls file)

teamstepps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.xlsx

July 01, 2016 - Patient Safety PSI 03 Pressure Ulcer 1.2 1.3 7 $109,870 $ 769,087 N 6 7 7 Y Y Y Y Y PSI 06 Iatrogenic … 13 Postoperative Sepsis 12.7 11.7 15 $49,215 $ 738,225 N 9 7 3 Y Y Y Y Y PSI 14 Postoperative Wound … Accidental Puncture or Laceration 3.2 3.3 1 $22,629 $ 22,629 Y 4 3 7 Y N Y Y Y Obstetric PSI 17 Birth Trauma-Injury … to Neonate 0.0 0.1 0 $88,000 $ - 0 N 2 3 9 Y Y Y Y Y PSI 18 Obstetric Trauma-Vaginal Delivery … Postoperative Sepsis Rate 0.0 16.2 0 $117,815 $ - 0 N 9 10 10 Y Y Y Y Y PDI 11 Postoperative Wound

Selected Best Practices and Suggestions for Improvement (pdf file)

teamstepps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf

May 17, 2016 - o Decreased central nervous system input (head injury, ingestion of central nervous system depressant … o Peripheral nerve/neuromuscular junction (spinal cord injury, organophosphate/carbamate poisoning, … expansion exercises with children, such as incentive spirometry, deep breathing, intermittent positive-pressure … breathing, and continuous positive airway pressure. … Noninvasive positive pressure ventilation for acute respiratory failure in children: a concise review

Declines in Hospital-Acquired Conditions (pdf file)

teamstepps.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-rates-2019-updated.pdf

January 01, 2019 - Conditions National efforts to reduce hospital-acquired conditions such as adverse drug events and injuries … CLABSI+ -6% Clostridioides difficile Infections -37% Falls -5% Obstetric Adverse Events -3% Pressure

Health Care Facility Design Safety Risk Assessment Toolkit | Agency for Healthcare Research and Quality

teamstepps.ahrq.gov/patient-safety/settings/hospital/resource/safety-assess.html

October 01, 2020 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … The toolkit: Targets six areas of safety—infections, falls, medication errors, security, injuries of