-
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.
-
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
-
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
-
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).
-
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.
-
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
-
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.
-
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
-
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.
-
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.
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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.
-
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.