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241. 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.

242. 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

243. NPSD Data Spotlight: Patterns of Fall Interventions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-patterns-fall-interventions.pdf
     September 01, 2023 - COMMON INTERVENTION(S) IN PLACE FOR PATIENTS WITH DIFFERENT DEMOGRAPHICS OR RISKS OF FALLS OR INJURIES … /Surgical Supply, Fall, Healthcare-Associated Infection, Medication or Other Substance, Perinatal, Pressure … health considerations.1–4 Falls result in significant physical and economic burden, ranging from injuries … Incidence of and county variation in fall injuries in US residents aged 65 years or older, 2016-2019 … Trends in fatal and nonfatal injuries among older Americans, 2004– 2017. Am. J. Prev.

244. 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?

245. 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

246. 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.

247. 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?

248. 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

249. 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.

250. Final Progress Report: Producing Evidence: Coordination within a Multiteam System Makes Healthcare Safer (pdf file)
     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.

251. 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

252. 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.

253. Case Scenarios: Handling Challenging Communications | Agency for Healthcare Research and Quality
     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

254. Final Progress Report: Transdisciplinary Learning Lab To Eliminate Patient Harm and Reduce Waste (pdf file)
     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).

255. Chapter 2. Fall Response | Agency for Healthcare Research and Quality
     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.

256. Background for AHRQ Quality Indicators
     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

257. Risk-Based Patient Safety Metrics (pdf file)
     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

258. PS Grantee | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/index.html?page=8
     January 01, 2024 - Publication Date: March 2015 Using an Electronic Health Record To Examine Nurse Continuity and Pressure … Coordination, Health Information Technology and Health Information Exchange, Human and Environmental Factors, Pressure … Information Exchange Publication Date: December 2014 Communication To Prevent and Respond to Medical Injuries

259. Table 8G: HCBS Population Age 65 | Agency for Healthcare Research and Quality
     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

260. Table 8A: National HCBS Population | Agency for Healthcare Research and Quality
     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