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  1. www.ahrq.gov/sites/default/files/2024-01/jones2-report.pdf
    January 01, 2024 - ,3 with an average associated excess cost of $7,000 per injury.4 Regardless of injury, falling can lead … .35 Consequently, randomized controlled trials of individual processes, such as use of bed/chair pressure … Supervisor/Manager Expectations & Actions Promoting Patient Safety (α = .92) 83 80 .88 Whenever pressure … REFINE (REducing Falls in In-patieNt Elderly) using bed and bedside chair pressure sensors linked to … Circumstances of patient falls and injuries in 9 hospitals in a Midwestern healthcare system.
  2. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/a2_pdi_boardpresentation.pptx
    October 01, 2015 - Rate NQI 03 Neonatal Blood Stream Infection Rate PDI 01 Accidental Puncture or Laceration Rate PDI 02 Pressure … PDI 09 Postoperative Respiratory Failure Rate PDI 10 Postoperative Sepsis Rate PDI 11 Postoperative Wound … in 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). … An Example: Pressure Ulcer (PDI 02) Tool A.2 Slide ‹#› Pediatric Toolkit for Using the AHRQ Quality
  3. www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/scenarios.html
    August 01, 2022 - Eventually the team is able to re-establish Mary's normal heart rate, blood pressure, and adequate blood … During the resuscitation efforts, information obtained from the devices monitoring Mary's EKG, blood pressure … Over the next few days, it is clear that he has suffered a significant brain injury due to the lack of
  4. www.ahrq.gov/sites/default/files/2025-03/sapirstein-report.pdf
    January 01, 2025 - A PUP CONOPs outlined key operational needs, metrics, and use cases for pressure ulcer prevention. … As a final step, methods and findings from the pressure injury use case were fed back into the CONOPS … conducted over the course of several workshops, utilizing the clinical expertise key stakeholders in wound … critical, life-threatening conditions receive constant monitoring and therapy to prevent significant injuries … The Financial Impact of Pressure Ulcers (White paper).
  5. www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man2.html
    December 01, 2017 - the nurse after a resident falls should include a review of the resident systems and description of injuries … Postural blood pressure and apical heart rate. Finger stick glucose (for diabetics). … The presence or absence of a resultant injury is not a factor in the definition of a fall. … A fall without injury is still a fall.
  6. www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2021qdr-appendixes.pdf
    December 01, 2021 - 1,000 elective-surgery admissions of length 4 or HCUP 2018 Reclosure of postoperative abdominal wound … dehiscence per 1,000 2 or more days, adults HCUP 2018 Home health care patients whose surgical wound … 2018 Home health improved care patients whose management of oral medications OASIS 2018 Birth trauma … with pressure ulcer MDS 2018 Low-risk, and left in long-stay nursing the bladder home residents … QUALITY MAP Measure Title Data Source Data Year Home health care patients whose surgical wound
  7. www.ahrq.gov/sites/default/files/2024-10/gorelick-report.pdf
    January 01, 2024 - The majority of these are intended for use in trauma patients, including the Injury Severity Score, … Trauma Score, and Pediatric Trauma Score. 35 Others are available for asthma,36 croup,37 and febrile … intravenous fluids • oxygen • prescription medications administered in ED (oral, IV, or inhaled) • wound … The Injury Severity Score: a method for describing patinets with multiple injuries and evaluating … The Injury Severity Score is unable to differentiate between poor care and severe injury.
  8. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Scanlon_62.pdf
    March 25, 2008 - human error,” and people make such attributions with all of their biases and under different kinds of pressures … an injury occurs. … Ideally, a patient safety program would use injury-based metrics to calculate an injury rate that could … That rate would be: Identified injuries Potential opportunities for those injuries to occur As … Identified injuries also become a source of risk identification, regardless of whether or not the injury
  9. www.ahrq.gov/news/newsletters/e-newsletter/970.html
    August 01, 2025 - This tool is designed to encourage patients with hypertension to consistently monitor their blood pressure … have a tool that is understandable to the patient and doesn’t cause them to worry about their blood pressure … Using deep learning for estimation of time-since-injury in pediatric accidental fractures.
  10. www.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. 
  11. www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8b.html
    February 01, 2023 - 19,884   Min 8,723 s s s s   Max 39,914 44,860 74,074 109,091 s Pressure … 11,656 7,935 10,256   Max 34,059 41,284 22,863 50,576 50,856 32,463 44,228 Pressure
  12. www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8c.html
    February 01, 2023 - 12,152   Min 3,503 s s s s   Max 29,139 28,882 33,333 57,143 s Pressure … s s 3,109 s   Max 19,830 35,256 29,840 68,293 96,970 25,549 36,882 Pressure
  13. www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8e.html
    February 01, 2023 - 15,175   Min 9,170 s s s s   Max 49,738 48,185 50,000 88,889 s Pressure … s 5,975 8,746   Max 44,606 51,218 33,445 80,351 102,632 52,215 42,172 Pressure
  14. www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8g.html
    February 01, 2023 - 23,974   Min 13,559 s s s s   Max 51,766 57,143 95,238 65,509 s Pressure … 11,836 13,626 18,523   Max 54,523 48,091 s 49,755 49,129 42,431 53,347 Pressure
  15. www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8.html
    February 01, 2023 - 17,845   Min 7,027 9,302 s s s   Max 36,997 40,253 41,379 51,572 s Pressure … 11,836 6,378 8,163   Max 29,607 39,709 25,788 49,755 49,129 29,454 42,207 Pressure
  16. www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8d.html
    February 01, 2023 - 4,484   Min 2,636 s s s s   Max 10,521 14,248 15,129 53,571 s Pressure … 7,984 s 1,713 s   Max 9,546 12,167 7,955 38,424 95,652 9,389 12,785 Pressure
  17. www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8f.html
    February 01, 2023 - 22,643   Min s s s s s   Max 42,799 51,459 68,293 75,000 s Pressure … 5,672 s s 3,977 6,993   Max 41,783 55,696 50,219 s s 49,115 47,727 Pressure
  18. Mod5-Case-Scenarios (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-case-scenarios.pdf
    April 01, 2016 - Eventually the team is able to re-establish Mary’s normal heart rate, blood pressure, and adequate blood … During the resuscitation efforts, information obtained from the devices monitoring Mary’s EKG, blood pressure … Over the next few days, it is clear that he has suffered a significant brain injury due to the lack
  19. www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man4.html
    December 01, 2017 - If there is a drop of 20 mm Hg or more in the resident's systolic pressure 1 minute after standing, the … Use of pressure, position, seat belt or other alarm. … Room sensors to detect resident movement; position or pressure alarms on the bed, chair or wheelchair … Trying to climb over bedrails may well result in a serious fall related injury. … For residents who are in danger of head injury, a helmet can provide protection.
  20. www.ahrq.gov/sites/default/files/2024-01/stifter-report.pdf
    January 01, 2024 - outcomes are limited, depicting some negative findings, including increased errors,62-63 needle stick injuries … With the ongoing financial pressures faced by hospitals, the erosion of nursing services will continue … Work schedule, needle use and needle stick injuries among registered nurses. … Hospitalizations related to pressure ulcers among adults 18 years and older. … Pressure ulcers: A patient safety issue.

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