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  1. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/f1_pdi_returnoninvestment.pdf
    January 01, 2013 - For example, improvement actions might reduce hospital-associated infections, rates of pressure ulcers … Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization
  2. www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023qdr-data-sources.pdf
    December 01, 2023 - state-specific data on preventive health practices and risk behaviors that are linked to chronic diseases, injuries … from each family in the house and collects data on topics including health status and limitations, injuries … patient’s age, gender, race, and ethnicity; patient’s expressed reason for visit; intentionality of injury … include mode of arrival, waiting time, duration of time in the ED, initial vital signs, and cause of injury … ulcer adverse events Pressure Ulcer Venous thromboembolism/pulmonary embolism (VTE/PE) not related
  3. www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2022qdr-datasources.pdf
    December 01, 2022 - state-specific data on preventive health practices and risk behaviors linked to chronic diseases, injuries … The examination includes physical measurements, such as blood pressure and dental examinations, and … from each family in the house and collects data on topics including health status and limitations, injuries … patient’s age, gender, race, and ethnicity; patient’s expressed reason for visit; intentionality of injury … ulcer adverse events Pressure Ulcer Venous thromboembolism/pulmonary embolism (VTE/PE) not related
  4. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-older-adults-references.html
    September 01, 2024 - Normal pressure hydrocephalus and mania symptoms: case report. … against overtesting, overdiagnosis, and overtreatment of older adults: thinking beyond imaging and injuries
  5. www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
    December 01, 2017 - reengineer the system to catch holes before they line up, and end system gaps that lead to a patient injury … It’s tough when the pressure is high and the patient is at risk.
  6. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_fullcolor.pdf
    May 01, 2017 - Root cause analyses of adverse events and near-misses (events that did not produce patient injury) … The AHRQ Patient Safety Indicator 18 (Obstetric Trauma–Vaginal Delivery with Instrument) decreased … in-house neonatal death, uterine rupture during labor, unplanned maternal admission to ICU, birth trauma … processes at the point of care to include specific maternal parameters, including blood loss, blood pressure … They established a standard process for blood pressure measurement upon admission and during labor
  7. www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0085maternity.pdf
    February 23, 2012 - Larger infants have increased rates of birth trauma, shoulder dystocia, and cesarean delivery. … delivery are at much higher risk for rehospitalization for uterine infection and obstetrical surgical wound … (ACOG, 2006, Level A)  Median episiotomy is associated with higher rates of injury to the anal sphincter … with episiotomy can be considered worse since some proportion of women who would have had lesser injury … Preventing perineal trauma during childbirth: a systematic review.
  8. www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0082maternity.pdf
    February 23, 2012 - Larger infants have increased rates of birth trauma, shoulder dystocia, and cesarean delivery. … delivery are at much higher risk for rehospitalization for uterine infection and obstetrical surgical wound … (ACOG, 2006, Level A)  Median episiotomy is associated with higher rates of injury to the anal sphincter … with episiotomy can be considered worse since some proportion of women who would have had lesser injury … Preventing perineal trauma during childbirth: a systematic review.
  9. www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0084maternity.pdf
    February 23, 2012 - Larger infants have increased rates of birth trauma, shoulder dystocia, and cesarean delivery. … delivery are at much higher risk for rehospitalization for uterine infection and obstetrical surgical wound … (ACOG, 2006, Level A)  Median episiotomy is associated with higher rates of injury to the anal sphincter … with episiotomy can be considered worse since some proportion of women who would have had lesser injury … Preventing perineal trauma during childbirth: a systematic review.
  10. www.ahrq.gov/sites/default/files/wysiwyg/CHIPRA-BMI-Maternity-Care-Measures.pdf
    February 23, 2012 - Larger infants have increased rates of birth trauma, shoulder dystocia, and cesarean delivery. … delivery are at much higher risk for rehospitalization for uterine infection and obstetrical surgical wound … (ACOG, 2006, Level A)  Median episiotomy is associated with higher rates of injury to the anal sphincter … with episiotomy can be considered worse since some proportion of women who would have had lesser injury … Preventing perineal trauma during childbirth: a systematic review.
  11. www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0085maternitycare.pdf
    February 23, 2012 - Larger infants have increased rates of birth trauma, shoulder dystocia, and cesarean delivery. … delivery are at much higher risk for rehospitalization for uterine infection and obstetrical surgical wound … (ACOG, 2006, Level A)  Median episiotomy is associated with higher rates of injury to the anal sphincter … with episiotomy can be considered worse since some proportion of women who would have had lesser injury … Preventing perineal trauma during childbirth: a systematic review.
  12. www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-current-state.pdf
    January 01, 2024 - that patients with diagnosis-related claims were 2.33 times more likely to die than to have a minor injury … and have been associated with increased medical errors and stress, anxiety, and burnout.113,114 Time pressure … diagnostic safety found the need to prioritize research on system factors, such as workload, time pressure … Preventable diagnostic errors in fatal cervical spine injuries: a nationwide register-based study from … Adv Wound Care (New Rochelle). 2013 Dec;2(10):588-592. http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3865615
  13. www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/hospital/compare/WR_751_AHRQ_Quigley_08_26_10.pdf
    April 01, 2010 - There had been minor setbacks in the initial timeline due to threats of nursing strikes and pressures … • Don’t let initial pushback from stakeholders or external pressures derail QI efforts; stay focused … specialized intensive care units, state-of-the-art inpatient and outpatient operating suites, a Level-1 trauma … There had been minor setbacks in the initial timeline due to threats of nursing strikes and pressures … medical doctor referrals to hospital specialists • Hospital workforce data o Vacancy rate o Workplace injuries
  14. www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dxsafety-ehr-impact.pdf
    August 01, 2024 - Furthermore, because hospitals are reimbursed based on diagnosis-related groups, they face financial pressures … test results, notes on the wrong patient, and errors on which side of the body was the site of the injury
  15. www.ahrq.gov/patient-safety/reports/liability/corbett.html
    August 01, 2017 - An adverse event is defined as an injury resulting from health care management, rather than the underlying … from a rural hospital recommended “Organize the paperwork with separate categories to clearly define ‘wound
  16. www.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-mental-health-bmjqs.pdf
    April 15, 2024 - Despite the importance of effective data gathering and synthesis, time pressures, competing priorities … J Trauma Dissociation 2017;18:233–47. 31 Sheehan DV, Lecrubier Y, Sheehan KH, et al. … procedures: are diagnosticians influenced by the narrative fallacy when assessing the psychological injuries … of trauma victims Psychol Inj Law 2016;9:265–71. 54 Jenkins MM, Youngstrom EA.
  17. www.ahrq.gov/sites/default/files/2025-02/catchpole2-report.pdf
    January 01, 2025 - Medication Errors and Injuries. … familiarity with workspace, providers or devices; unwillingness to collaborate; and uncertainty, time pressures
  18. www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital-user-guide.pdf
    July 01, 2018 -  “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events … Whenever pressure builds up, my supervisor/manager wants us to work faster, even if it means taking shortcuts … Whenever pressure builds up, my supervisor/manager wants us to work faster, even if it means taking
  19. www.ahrq.gov/sites/default/files/wysiwyg/cpi/about/mission/budget/2021/FY_2021_CJ_NIRSQ.pdf
    January 01, 2021 - Rounds on the Web); • AHRQ QuestionBuilder App; • AHRQ’s Safety Program for Nursing Homes: On-Time Pressure … scans ordered, higher physician trust, and higher patient knowledge in cases involving minor head injuries

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