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361. 2019 National Healthcare Quality and Disparities Report Quality Trends (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr-core-measures-quality.pdf
     January 01, 2019 - 51.9% in 2013 67.7% in 2017 -9.5 0.006 Surgical Safety Home health care patients whose surgical wound … single measure that was not changing over time examines long-stay nursing home patients who experience injuries … Ulcers Short-stay nursing home patients with new or worsening pressure ulcers (MDS) 0.7% in 2013 … Ulcers High-risk, long-stay nursing home patients with pressure ulcer (MDS) 5.3% in 2013 4.8% in … 2017 -2.1 0.018 Falls Long-stay nursing home patients experiencing one or more falls with major injury

362. Toolkit for Reducing CAUTI in Hospital Units: Implementation Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide.pdf
     September 01, 2015 - ulcers or similarly severe wounds that cannot be kept clear of urinary incontinence despite wound care … require strict prolonged immobilization following specific types of trauma or surgery. … Examples include instability in the thoracic or lumbar spine, multiple traumatic injuries such as pelvic … Intermittent catheterization is most often used in patients with neurogenic bladder or spinal cord injury … despite wound care and other urinary management strategies, if ISC is adequate to manage the type of

363. Toolkit for Reducing CAUTI in Hospital Units: Implementation Guide (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/implementation-guide_0.pdf
     September 01, 2015 - ulcers or similarly severe wounds that cannot be kept clear of urinary incontinence despite wound care … require strict prolonged immobilization following specific types of trauma or surgery. … Examples include instability in the thoracic or lumbar spine, multiple traumatic injuries such as pelvic … Intermittent catheterization is most often used in patients with neurogenic bladder or spinal cord injury … despite wound care and other urinary management strategies, if ISC is adequate to manage the type of

364. Practice and Quality Improvement | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/reports/2024-annual-report/recent-grants-improvement.html
     May 01, 2024 - Appendix D: Grant Summaries P1: Does A New Care Model Improve Care for Patients with Acute Kidney Injury … would improve the use of a hypertension focused clinical decision support to effectively improve blood pressure … support in rural primary care practices to provide evidence-based clinical care recommendations for blood pressure … program that supports patients discharged from the hospital to home after an episode of acute kidney injury … health improvement project in 60 primary care clinics throughout Alabama to improve rates of blood pressure

365. Do Transient Working Conditions Trigger Medical Errors? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Grayson.pdf
     January 01, 2003 - .6, 10–12 Injuries to workers result from a causal chain of events involving both latent and immediate … Indeed, many risk factors for injury that have been studied in case-crossover studies of injury are … circumstances may be the result of other working conditions, such as a hectic work environment, time pressures … Case-crossover studies of occupational trauma: methodological caveats. … Injury Prevention 2001;7:Supplement 38–42.

366. Fundamentals of Medicare Patient Safety Surveillance: Intent, Relevance, and Transparency (pdf file)
     www.ahrq.gov/downloads/pub/advances/vol2/Hunt.pdf
     July 01, 2004 - This urgency is, in part, precipitated by the confluence of market pressures to demonstrate value in … DVT/PE* Hospital acquired UTI** Ventilator associated pneumonia** Adverse drug events ** Pressure … care postoperative stays has shifted the diagnostic location for a large percentage of postoperative wound … reliable proxies for this event in the administrative claims, our ability to identify postoperative wound … A study of medical injury and medical malpractice: an overview.

367. Fundamentals of Medicare Patient Safety Surveillance: Intent, Relevance, and Transparency (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Hunt.pdf
     July 01, 2004 - This urgency is, in part, precipitated by the confluence of market pressures to demonstrate value in … DVT/PE* Hospital acquired UTI** Ventilator associated pneumonia** Adverse drug events ** Pressure … care postoperative stays has shifted the diagnostic location for a large percentage of postoperative wound … reliable proxies for this event in the administrative claims, our ability to identify postoperative wound … A study of medical injury and medical malpractice: an overview.

368. Communication: Obstetric Hemorrhage - PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_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, … Her blood pressures have remained normotensive, and she has had good reflexes throughout the shift. … Her blood pressures have remained normotensive, and she has had good reflexes throughout the shift.” 

369. Appendix B. Clinical Materials to Share With Primary Care Providers | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/resource/nicu/packet/apb.html
     December 01, 2013 - supplementation, mechanical ventilation, air leaks, pulmonary edema, PDA ligation, infection causing lung injury … Blood pressure: Not higher in infants with nephrocalcinosis, but overall higher in preterm infants … Should have: Blood pressure checked at every visit. … diarrhea are at risk for zinc deficiency and may need supplementation: Poor growth, diarrhea, impaired wound

370. Appendix B. Clinical Materials to Share With Primary Care Providers | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/resource/nicu/packet/apb.html
     December 01, 2013 - supplementation, mechanical ventilation, air leaks, pulmonary edema, PDA ligation, infection causing lung injury … Blood pressure: Not higher in infants with nephrocalcinosis, but overall higher in preterm infants … Should have: Blood pressure checked at every visit. … diarrhea are at risk for zinc deficiency and may need supplementation: Poor growth, diarrhea, impaired wound

371. Regulation of Health Policy: Patient Safety and the States (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Weinberg.pdf
     March 01, 2004 - In this research, we examined State legislative responses to pressure from constituents and policymakers … or disability or the immediate danger of serious injury or disability”); and Class C (an adverse event … Nevada defines a sentinel event as “an unexpected occurrence” involving death or serious injury or the … According to JCAHO, the classification of an AE that was avoided or did not result in injury is drawn … In recent years, State legislatures have deflected pressure to regulate health care away from the Federal

372. Final Progress Report: Individualized Performance Feedback on Venous Thromboembolism Prevention Practice (pdf file)
     www.ahrq.gov/sites/default/files/2025-06/haut-report.pdf
     January 01, 2025 - handwashing, VTE prevention, medication prescribing, diagnostic imaging, medication reconciliation, pressure … injury prevention, antibiotic use, discharge summary, and laboratory testing. … Receive feedback Want feedback Patient nutrition Medication reconciliation Handwashing Pressure … injury prevention VTE Prevention Antibiotic use Medication prescribing Discharge summary

373. The National Action Alliance to Advance Patient Safety Summer Webinar Series - PowerPoint Presentation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/public-action-alliance-slides-040323_LOCKED.pdf
     May 25, 2023 - factors focus areas • Workplace Change Collaborative – National Framework on Burnout and Moral Injury … “By and large, the U.S. does not account for medical care injuries and deaths in our vital statistics … Where it should say 'medical care harm/injuries', it's blank. … as surge … our new normal *Healthcare Acquired Infections, Early Elective Deliveries, Falls with Injury … , Healthcare Acquired Pressure Injuries, NTSV C-Section patients to get to WHO Goal, Sepsis Mortality

374. Survey on Patient Safety (facility version) (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
     June 02, 2025 - · “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

375. Guide-Infection-Prevention (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/guides/guide-infection-prevention.pdf
     March 01, 2017 - ▪ Infections cause pain, injury, disability, and sometimes even death, and can be very expensive … ▪ Cover all cuts and wounds with a dressing. … resident, if needed, that the law requires the use of safety lancets and needles to prevent needle stick injuries … ▪ Make sure that wounds are covered. ▪ Contain any urine, stool, or wound drainage. … ▪ An LTC facility must have negative pressure rooms and a respiratory fit-test program in order to

376. Building a Team and Process to Reduce CAUTI Risk (April 8, 2015) | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/building-teamwork-transcript.html
     December 01, 2017 - The fourth indication is the healing of open wounds that are close to the groin area. … , such as a motor vehicle accident where they have an injury to the spinal cord. … Assisting healing with a perineal or sacral wound in certain patients. … or multiple traumatic injuries, such as multiple fractures, and you worry that, again, movement will … Wound care nurses, we talked about, the pressure associated with the Foley catheter is helping.

377. Paul Tedrick (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/building-team-transcript.doc
     April 08, 2014 - The fourth indication is the healing of open wounds that are close to the groin area. … , such as a motor vehicle accident where they have an injury to the spinal cord. … Assisting healing with a perineal or sacral wound in certain patients. … or multiple traumatic injuries, such as multiple fractures, and you worry that, again, movement will … Wound care nurses, we talked about, the pressure associated with the Foley catheter is helping.

378. Comparison Tables for Making Healthcare Safer Reports | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/making-healthcare-safer/comparison.html
     June 01, 2025 - (Not reviewed) (Not reviewed) (Not reviewed) Interventions To Prevent Contrast-Induced Acute Kidney Injury … Summary of Evidence (all patients) (Not reviewed) (Not reviewed) Preventing Patient Death or Serious Injury … Summary of Evidence Summary of Evidence (all patients) (Not reviewed) (Not reviewed) Prevention of Pressure

379. Care Coordination Quality Measure for Primary Care (CCQM-PC) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/coordination/ccqmpc/cati-script.pdf
     July 01, 2016 - able to walk a flight of stairs without losing your breath, or target rates —for example, a blood pressure … In the last 12 months, if you had an illness or injury, how often did your primary care provider or … professionals in this office ask whether you had enough services to help you take care of this illness or injury … NEEDED] 1 Never 2 Sometimes 3 Usually 4 Always, or 5 I did not have an illness or injury … High blood pressure or hypertension? 66e. Congestive heart failure? 66f.

380. Healthcare Safety Competencies Affinity Group Environmental Scan (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/engineering-safety-practice/healthcare-safety-competency-environmental-scan.pdf
     March 27, 2025 - including central line-associated bloodstream infections, ventilator-associated events, hospital-acquired pressure … injuries, patient falls, and catheter-associated urinary tract infections during the COVID-19 pandemic … Bureau of Labor Statistics, in 2018, healthcare workers accounted for 73% of all nonfatal workplace injuries … Safety Science- Adjacent • Workload Management • Burnout • Worker Safety • Fatigue • Moral Injury … The Human Experience • Burnout • Co-Design • Fatigue • Improving Access to Care • Moral Injury