-
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/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/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/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/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/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/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/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/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/natlhacratereport-rebaselining2014-2016_0.pdf
January 01, 2016 - patient safety events, including
many types of hospital-acquired infections, adverse drug events, and injuries … Ulcers/Pressure Injuries
Surgical Site Infections
Ventilator-Associated
Pneumonias
(Post-op) Venous … Central Venous Catheters
Falls MPSMS In-Hospital Patient Falls
Obstetric
Adverse
Events
PSI OB Trauma … National number of adverse events captured by PSIs 18 and 19 on obstetric
injury and national number … 8,513 0.29
Falls MPSMS In-Hospital Patient Falls 238,965 8.03
Obstetric
Adverse
Events
PSI OB Trauma
-
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.
-
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/action-alliance/engineering-safety-practice/index.html
April 01, 2025 - that make it more difficult for people to make errors in care delivery or experience a work-related injury … Healthcare Settings includes strategies to identify risks and hazards and prevent/control work-related injury … Healthcare-Associated Infections Program (contains multiple resources and toolkits). * Preventing Pressure
-
www.ahrq.gov/sites/default/files/2025-05/goldman2-report.pdf
January 01, 2025 - constraints impact the coordination and delivery of care, and patients suffer unexpected
complications and injuries … sequence of preceding events, the specific end states that are modeled can range from a
specific patient injury … Blood pressure regulatory functions are modeled as a subsystem of both the mother
and the fetus. … A common initiating event or failure is blood pressure lability that can ultimately
lead to one or more … Risk is perhaps best depicted as a dynamic situation in which two events –
progression to injury and
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereport-slides.html
September 01, 2017 - showing 15 active medications during the report week, active high-risk diagnosis of UTI, stage III pressure … DNR,DNH, MOLST, or POLST Order in Place
Oxygen Therapy
Catheter or Ostomy Present
Stage II or > Pressure … Gastrointestinal/
Genitourinary
Symptoms
Endocrine/
Metabolic/
Nutrition
Issues
Wound … Genitourinary
Endocrine/
Nutritional/
Metabolic
Musculoskeletal/
Joint
Symptoms
Wound … Circulatory Problems
Hypertension or Renal Failure
Gastroenteritis
Angina Pectoris
Falls /Trauma
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/find5.html
December 01, 2012 - higher rates on all measures other than Short-Term Complications of Diabetes, Bacterial Pneumonia, and Pressure … The exceptions are Pressure Ulcer, which is effectively equal in urban and nonurban areas, and Infection … Rates for women in the Medicaid-only population are always higher than for men except in Pressure Ulcer … The main exception to the county-level age pattern is the Pressure Ulcer measure, for which rates are … The pattern is strong for all conditions except high blood pressure.
-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/healthyliving/qdr2015-chartbook-healthyliving.pdf
January 01, 2020 - , and
■ Birth trauma not elsewhere classified.
24
Many of these injuries to neonates may be preventable … .
25
Birth trauma—injury to neonate per 1,000 live births, 2004-2013
0.0
0.5
1.0
1.5
2.0
2.5 … Trends:
■ Birth trauma-neonatal injury rates fell from 2.6 per 1,000 live births in 2004 to … ■ Between 2004 and 2013, birth trauma-neonatal injury rates fell for all racial/ethnic
groups, … Birth Trauma Rate—Injury to Neonate: Technical Specifications.
-
www.ahrq.gov/news/blog/ahrqviews/world-patient-safety-day-2024.html
September 01, 2024 - common individual adverse events for populations with sufficient size for analysis were: 1) worsening pressure … injuries that were present on admission (2021: 4.9 percent, 2022: 6.0 percent), 2) hypoglycemic events
-
www.ahrq.gov/hai/pfp/haccost2017-ref.html
May 01, 2023 - Costs of venous thromboembolism, catheter-associated urinary tract infection, and pressure ulcer. … The costs of medical falls by component of cost, timing, and injury severity. … Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization … Ostomy Wound Manage . 2016 Nov;62(11):30-8.
65. Mendizabal A, Thibault DP, Willis AW. … Marginal hospital cost of surgery-related hospital-acquired pressure ulcers.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/mcc/mccchartbook.pdf
April 01, 2014 - -4 NO YES
861 HEART & LUNG INJURY -5 NO -4 NO
863 GI TRACT INJURY -4 NO -3 NO
864 LIVER INJURY - … 3 NO -3 NO
869 INTERNAL INJURY NOS -3 NO -3 NO
871 EYEBALL OPEN WOUND -3 NO -4 NO
872 OPEN WOUND OF … OPEN WOUND OF LOWER ARM -5 NO -5 NO
882 OPEN WOUND OF HAND -5 NO -5 NO
883 OPEN WOUND OF FINGER -5 … 893 OPEN WOUND OF TOE -5 NO -5 NO
904 BLOOD VESSEL INJURY NEC -5 NO -4 NO
908 LATE EFF INJURY NEC … TO NERVE NEC/NOS -4 NO -4 NO
958 EARLY COMPLIC OF TRAUMA -4 NO -3 NO
959 INJURY NEC/NOS -4 NO -3 NO