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221. Overuse of Imaging (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-195-section-2.pdf
     January 01, 2016 - seizure or convulsions associated with trauma  History of loss of consciousness associated with trauma … neurologic examination or signs or symptoms of intracranial hemorrhage or increased intracranial pressure … Documentation of trauma ☐Yes ☐No 2b. … Mark “Yes” for mechanisms of injury such as penetrating trauma, fall from more than 5 feet, pedestrian … abnormal neurologic examination, signs and symptoms of intracranial hemorrhage or increased intracranial pressure

222. Overuse of Computed Tomography Scans for the Evaluation of Children with a First Generalized Afebrile, Atraumatic Seizure: Tables 1-9 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0198-tables1-9.pdf
     June 02, 2025 - seizure 780.32 Post-traumatic seizure 780.33 Other convulsions 780.39 Table 3 [=IMG9]: Head Trauma … 852.x Other/unspecified intracranial hemorrhage following injury 853.x Intracranial injury of other … 61106 Twist drill hole for subdural or ventricular puncture; for implanting ventricular catheter or pressure … intracerebral 61156 Burr hole(s); for implanting ventricular catheter, reservoir, eeg electrode(s), pressure … excision of foreign body from brain 61570 Craniectomy or craniotomy; with treatment of penetrating wound

223. Technical Interventions To Prevent CAUTI | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/guides/implguide-pt3.html
     October 01, 2015 - ulcers or similarly severe wounds that cannot be kept clear of urinary incontinence despite wound care … require strict prolonged immobilization following specific types of trauma or surgery. … Examples include instability in the thoracic or lumbar spine, multiple traumatic injuries such as pelvic … Intermittent catheterization is most often used in patients with neurogenic bladder or spinal cord injury … despite wound care and other urinary management strategies, if ISC is adequate to manage the type of

224. Chartbook on Healthy Living: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/chartbooks/healthyliving/healthyliving-slides.html
     April 01, 2018 - Patient Safety: Birth trauma—injury to neonates. … Birth trauma not elsewhere classified. 24 Many of these injuries to neonates may be preventable … . 25 Slide 42 Birth trauma—injury to neonate per 1,000 live births, 2004-2013 Image: Chart … Overall Rate: In 2013, the birth trauma-neonatal injury rate was 1.9 per 1,000 live births. … Birth Trauma Rate—Injury to Neonate: Technical Specifications.

225. Appendix B8: Unsafe Behavior Worksheet (Text Description) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb5txt.html
     December 01, 2017 - ( ) Postural hypotension ≥20 mm Hg drop in systolic pressure with position change … Orthostatic Hypotension Risk Factor: Unsafe Behavior Selected Interventions __ Low blood pressure … __ Behavior management strategies __ Increase assistance and surveillance    __ Position or pressure … _ Increase activities involvement    __ Other ___________________________ __ Reduce risk of injury

226. Overuse of Computed Tomography Scans for the Evaluation of Children with Atraumatic Headache: Report (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-206-fullreport.pdf
     November 01, 2019 - measure, atraumatic headaches are considered to be primary headaches or secondary headaches unrelated to injury … These complications include compromised airway, hypoxia leading to central nervous system injury, and … deep sedation carry a greater risk of airway compromise, hypoxia resulting in central nervous system injury … These risks include dental trauma; airway edema (swelling of the windpipe); vocal cord spasm or injury … ; regurgitation of stomach contents with subsequent aspiration (inhalation) pneumonia; injury to arteries

227. Making It Work Tip Sheet: Multidisciplinary Rounding for Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/multidiscplinary-rounding.pdf
     April 01, 2022 - – healthcare-associated infection prevention efforts • Performance improvement specialist – safety, pressure … injury, and falls concerns • Social worker – discharge planning • Family members/patient – may be included

228. Methods To Estimate the Baseline 2010 PFP National Hospital-Acquired Condition Rate (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/pfphac.pdf
     September 01, 2014 - With Central 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 data … The national number of adverse events captured by PSIs 18 and 19 on obstetric injury, and the national … Ulcers Hospital-Acquired Pressure Ulcers 53.03 62.45 0.85 VAP Ventilator-Associated Pneumonia … Falls MPSMS In-Hospital Patient Falls 262,317 32,750,000 8.010 Obstetric Adverse Events PSI OB Trauma

229. Final Progress Report: Reduction of Nephrotoxic Medication-Associated Acute Kidney Injury in Children (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/goldstein-report.pdf
     January 01, 2024 - Final Progress Report: Reduction of Nephrotoxic Medication-Associated Acute Kidney Injury in Children … rate (per exposure) 20.8% 15.0% -28 15.4% Acute kidney injury Intensity rate (Acute kidney injury … Effectiveness of home blood pressure monitoring, Web communication, and pharmacist care on hypertension … Modified RIFLE criteria in critically ill children with acute kidney injury. … Guideline for Acute Kidney Injury.

230. AHRQ-Funded Patient Safety Highlights: Improving Healthcare Safety by Supporting Measure Implementation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-measure-implementation.pdf
     August 01, 2025 - The difference between home and ED systolic blood pressures was not associated with anxiety and showed … These findings show that over half of ED patients with 2 elevated blood pressures and no history of … measure pain and anxiety scores in the ED in an attempt to understand the meaning of elevated blood pressures … Score (AIS)=5 head injury, other AIS=5 injury, or higher age groups. … than patients without a medical injury.

231. Board and Senior Leadership PowerPoint Presentations on the Pediatric Quality Indicators (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/a2_pdi_boardpresentation.pdf
     October 01, 2015 - October 2015: – Addition of information relevant to ambulatory and managed care encounters – Expanded injury … /TechSpecs/PDI%2002%20Pressure%20Ulcer %20Rate.pdf • Numerator: Discharges with ICD-10-CM code of pressure … • Several exclusions (e.g., length of stay <5 days, principal diagnosis of pressure ulcer). … An Example: Pressure Ulcer (PDI 02) http://www.qualityindicators.ahrq.gov/Downloads/Modules/PDI/V45/ … An Example: Pressure Ulcer (PDI 02)� How can the AHRQ PDIs be used in�quality assessment?

232. Behind the Scenes: Patient Safety in the Operating Room and Central Materiel Service During Deployments (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Vane.pdf
     February 01, 2005 - With this environment, it was necessary to extend the length of sterilization times, adapt pressure … Surgeries included multiple traumas and burns. … Patient Safety During Military Deployments 471 Combat missions involved trauma and burn surgeries … Humanitarian missions included trauma surgery along with a broad-based OR capability, which included … a number of surgical site wound infections.

233. Table A: Indicator Rates for the HCBS and Full Medicaid Populations (Rates of Admission per 100,000 Persons) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/oirtab.html
     December 01, 2012 - Composite: ACSC Acute Conditions 6,913 2,846 Composite: ACSC Overall 17,971 7,139 Pressure

234. Appendix B. Detailed Research Domain Framework Definitions and Classification Rules | Agency for Healthcare Research and Quality
     www.ahrq.gov/healthsystemsresearch/hspc-research-study/appendix-b.html
     June 01, 2020 - Examples of intermediate outcomes include clinical health measures (e.g., adequate control of blood pressure … Intermediate outcomes include measures related to the incidence of chronic conditions—such as high blood pressure … This category includes studies of population health, injury occurrence, and disease progression. … Examples of intermediate outcomes of care are blood pressure, asthma, and glycemic control.  … that primarily examine how to treat injuries or disease (even if the injury or disease is preventable

235. The Relationship Between Hospital Workload and Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/weissman-rothschild-report.pdf
     January 01, 2024 - Structured Abstract Purpose: Aim 1 of this study was to determine the extent to which hospital workload pressures … this study was to determine the extent to which hospital working conditions, specifically workload pressures … Operative organ injury Operative blood or lymph vessel injury or postoperative hemorrhage Postoperative … Adverse drug events and specific hospital-acquired infections (bloodstream, urinary tract, wounds, respiratory … Thus, seven wounds were missed by computerized surveillance when study patients had positive culture

236. Board and Senior Leadership PowerPoint Presentations on the AHRQ Quality Indicators (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a2_combo_boardpresentation.pdf
     October 01, 2015 - October 2015: – Addition of information relevant to ambulatory and managed care encounters – Expanded injury … • Several exclusions (e.g., length of stay <5 days, principal diagnosis of pressure ulcer). … • Several exclusions (e.g., length of stay <5 days, principal diagnosis of pressure ulcer). … A PSI Example: Pressure Ulcer (PSI 03)� What are the Inpatient Quality Indicators (IQIs)? … An Example: Pressure Ulcer (PDI 02)� How can the AHRQ QIs be used in quality assessment?

237. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4e_combo_psi08-postophipfx-bestpractices.pdf
     May 20, 2016 - In 2008 the Centers for Medicaid & Medicare Services (CMS) identified falls and trauma—including fractures—as … Prevention Protocol Use a standardized fall prevention protocol to help reduce falls and associated injury … /fallspx/fallspxmanual.pdf http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries … Transforming care at the bedside how-to guide: reducing patient injuries from falls.http://www.ihi.org … High blood pressure and bone-mineral loss in elderly white women: a prospective study.

238. Views of Emergency Medicine Trainees on Adverse Events and Negligence: Survey Results from an Emergency Medicine Training Program in a Regional Health Care System Following the National Standard of Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Shah_99.pdf
     March 23, 2008 - Two of these EDs are Level 1 Trauma Centers. … An adverse event was defined as “an injury caused by medical management error rather than the patient … The feeling of pressure from a day-to-day threat of malpractice litigation, as well as the ordering … Negligence may or may not produce patient injury; the former product is called an adverse event due to … The questionnaire used examples of adverse event injuries, but it did not consider threshold levels.

239. Communication: Severe Hypertension (pdf file)
     www.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

240. Session 1 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod3sess3.html
     October 01, 2014 - He has moderate dementia, and his blood pressure falls when he stands up too fast, making him dizzy. … Safety means avoiding, preventing, and lessening the effects of harm and injury while residents are in … To prevent injury from falls, all nursing staff need knowledge and skills. … Nursing staff must have the knowledge and skills to prevent injury from falls. … Injury Prevention and Control: Home and Recreational Safety; Falls in Nursing Homes.