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101. Examples of Patient Harm Related to Invasive Devices | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/phys-championsgd/section3.html
     October 01, 2015 - Teamwork and Communication Definitions and Tools Several examples of severe patient injury … Paraplegia (inability to walk) Ultimately, the patient underwent back surgery to decompress the pressure … The virulent organism caused a severe infection and irreversible injury to the patient. … She was found to have a fever of 102 °F, and her blood pressure dropped to 90 systolic.

102. On-Time Preventable Hospital and ED Visits Functional Specs (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevhospitalvisits-funcspecs_0.pdf
     August 01, 2017 - Ulcer Vendor determined or Wound Assessment Pressure ulcer Stage II, III, IV, or unstageable. … IF wound assessment date ≤7 days of report date AND at least one pressure ulcer with ulcer stage = … then display X in Wound • Infected wound or decubitus ulcer • Jaundice • Rash 10 Injury: Fall … X in Injury: 11 Injury: Non- Fall Related Transfer Note • • Major injury Minor injury IF …  Chest pain/angina  Dizzy/lightheaded Non-Fall-Related Injury  Major injury  Minor injury

103. Network of Patient Safety Databases Chartbook, 2019 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2019.pdf
     January 01, 2019 - event type; and, detailed information about specific event types, such as the distribution of various injuries … pertaining to nine patient safety event types that represent the majority of reported preventable injuries … Event-Specific Formats pertain to nine patient safety events that represent the great majority of preventable injuries … that they represent minor injuries such as soreness, bumps, and minor abrasions. … unstageable A lesion that, on admission, was a suspected Deep Tissue Injury A pressure ulcer at stage

104. Outcomes | Agency for Healthcare Research and Quality
     www.ahrq.gov/topics/outcomes.html
     Hospital Reduces Emergency Wait Time, Adverse Events Using AHRQ Tools Connecticut Hospital Reduces Pressure … Injuries Using AHRQ Toolkit Georgetown University Family Nurse Practitioner Program Trains Hundreds

105. Putoolssect7 (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressureulcertoolkit/putoolssect7.docx
     February 16, 2011 - Pressure ulcers are sterile wounds. 36. … Pressure ulcers are sterile wounds. False 36. … If a skin disruption is found, the type of skin injury will need to be identified. … For example is it a skin tear, a pressure ulcer, or moisture-associated skin damage or injury? … unit staff for pressure ulcer practice Certified Wound Care Nurse · Assesses wounds, does complex

106. Chartbook on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2020.pdf
     January 01, 2020 - pertaining to nine patient safety event types that represent the majority of reported preventable injuries … captures the specific type of physical injury sustained in the fall as TYPE OF INJURY AS RESULT OF … that they represent minor injuries such as soreness, bumps, and minor abrasions. … and the type of the injury. … unstageable A lesion that, on admission, was a suspected Deep Tissue Injury A pressure ulcer at stage

107. Labor and Delivery Unit Safety: Shoulder Dystocia | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/tool-shoulder-dystocia.html
     July 01, 2023 - Effects of shoulder dystocia training on the incidence of brachial plexus injury. … Shoulder dystocia and injuries: prevention and management. … McRoberts maneuver used concurrently with suprapubic pressure [Call time] hh:mm:ss)  ___ : ___ : __ … Suprapubic pressure: Using a closed fist over pubic bone, push in an inward and downward motion. … This procedure is considered a heroic measure due to the significant risk of brachial plexus injury associated

108. 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/hacrate2013_0.pdf
     October 01, 2015 - MPSMS (2013) In-Hospital Patient Falls 240,000 7.2 Obstetric Adverse Events PSI (2013) OB Trauma … Fall and injury prevention (Chapter 10). In: Hughes RG, ed. … Preventing falls and eliminating injury at Ascension Health. … The road to zero preventable birth injuries. … Eliminating birth trauma at Ascencion Health.

109. Puh-Electronic-Reports (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-electronic-reports.pdf
     February 10, 2014 - This report is helpful for nursing home staff and wound nurses to promote early identification of pressure … These details are available at the time the pressure ulcer is being assessed during wound rounds or … For example, the Pressure Ulcers At Risk for Delayed Healing Report; Weekly Wound Rounds Report; … DON or ADON, Nurse Manager, Wound Nurse, QI Director Root Cause Analysis for New Pressure Ulcers … Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance

110. Table 16A: Outcome Indicators by County Socioeconomic Status | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab16.html
     December 01, 2012 - 9,257 6,892 Composite: ACSC Overall 17,570 24,934 20,620 17,662 23,518 18,337 Pressure … 10,435 7,884 Composite: ACSC Overall 19,406 27,524 22,656 19,821 25,958 20,278 Pressure … 5,382 4,110 Composite: ACSC Overall 12,450 16,541 14,919 11,150 15,491 12,897 Pressure … 3,777 3,248 Composite: ACSC Overall 5,094 6,963 6,484 4,695 6,310 5,297 Pressure … 8,215 6,780 Composite: ACSC Overall 17,579 23,121 20,378 17,055 21,295 18,297 Pressure

111. AHRQ Quality Indicators Prioritization Worksheet Example (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.pdf
     April 02, 2025 - Postoperative Sepsis 12.7 11.7 15 $49,215 $ 738,225 N 9 7 3 Y Y Y Y Y PSI 14 Postoperative Wound … - Injury to Neonate 0.0 0.1 0 $88,000 $ - N 2 3 9 Y Y Y Y Y PSI 18 Obstetric … Trauma-Vaginal Delivery With Instrument 134.8 135.1 17 $90,000 $ 1,530,000 N 2 3 8 Y Y … Y Y Y PSI 19 Obstetric Trauma-Vaginal Delivery Without Instrument 17.0 17.9 5 $96,000 $ … Rate 0.0 16.2 0 $117,815 $ - N 9 10 10 Y Y Y Y Y PDI 11 Postoperative Wound

112. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits Training | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereportguide.html
     September 01, 2017 - Infected wound or decubitus. Jaundice. Rash. Fall-Related Injury. … Wound or skin issues. Fall-related injury. Non-fall-related injury. Abnormal labs. … Fall/trauma. Anemia. Diabetes. … Wound or skin issues. Fall-related injury. Non-fall-related injury. Abnormal labs. … Fall/trauma. Anemia. Diabetes.

113. On-Time Pressure Ulcer Healing: Introduction to Pressure Ulcer Healing Reports Facilitator Training Instructor's Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/erepguide.html
     December 01, 2016 - Pressure Ulcers at Risk for Delayed Healing. Weekly Wound Rounds Report. … home chains, and wound centers. … Injury Alliance. … The wound nurse, wound physician, and other disciplines attending wound rounds can see quickly which … If the pressure ulcer shows signs of delayed healing, as recorded on the wound assessment based on the

114. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.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

115. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4g_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

116. Chartbook on Hispanic Health Care: Slide Presentation—Part 2 | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/hisph-slides-pt2.html
     May 01, 2018 - Slide 39 Maternity Care for Hispanics Note: Trends: Birth trauma and obstetric trauma were … Slide 43 Birth trauma—injury to neonate per 1,000 live births, by race/ethnicity, 2004-2012 Image … : Graph shows birth trauma—injury to neonate per 1,000 live births: Year Total White Black … Note: Trends: Birth trauma-neonatal injury rates fell from 2.6 per 1,000 live births in 2004 … Between 2004 and 2012, birth trauma-neonatal injury rates fell for all racial/ethnic groups.

117. Documentation and Coding for the AHRQ Pediatric Quality Indicators (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/b4_pdi_documentationcoding.pdf
     March 15, 2016 - J Trauma 2007;63(5):1132-37. Iezzoni LI, Foley SM, Daley J, et al. 1992. … PDI 02 Pressure Ulcer Rate (stage III, IV, Unstageable) Diagnosis and site of pressure ulcer must … Document and code any associated pleural effusion or chest trauma. … Lack of Coding Specificity Measure Includes Only Elective Admissions PDI 11 Postoperative Wound … Dehiscence Rate X Depth of the wound dehiscence: external/superficial vs. internal/deep should

118. Appendix C. Case Study and Program Examples | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapc.html
     December 01, 2017 - She was assessed to have no injuries resulting from the fall. … Physical restraint—increases risk of serious injury. … Full side rails—increase risk of serious injury. … . ___ provide frequent reminders about call bell. ___ conduct trial use of a change in position/pressure … Use of pressure, position alarm. Use of hip protectors. No physical restraint use.

119. Preventing Pressure Ulcers in Hospitals: A Toolkit - Section 7, Tools and Resources (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressureulcertoolkit/putoolssect7.pdf
     January 01, 2004 - Pressure ulcers are sterile wounds. 36. … Pressure ulcers are sterile wounds. False 36. …  If a skin disruption is found, the type of skin injury will need to be identified. … For example is it a skin tear, a pressure ulcer, or moisture-associated skin damage or injury? … medical staff, wound team, and unit staff for pressure ulcer practice Certified Wound Care Nurse

120. IQI, PSI, AND PDI RATES GENERATED BY THE AHRQ WINDOWS QI SOFTWARE (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b2b_combo_ratesgenbywin.pdf
     March 01, 2016 - Rate 0 0 - 0.0006572 PDI1 PDI #1 Accidental Puncture or Laceration Rate 0 0 - 0.00053522 PDI2 PDI #2 Pressure … Count 0 - - - PSI2 PSI #2 Death Rate in Low-Mortality DRGs 8 132 0.06060606 0.00028197 PSI3 PSI #3 Pressure … Rate – Injury to Neonate 0 0 - 0.00210694 PSI18 PSI #18 Obstetric Trauma Rate – Vaginal Delivery With … Diagnosis Related Groups (DRGs) 8 132 0.060606 0.001046 57.95983 0.000282 0.016343 0.007641 PSI #3 Pressure … Rate - Injury to Neonate 0.002107 PSI #18 Obstetric Trauma Rate - Vaginal Delivery With