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381. 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

382. Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/studies/index.html?page=327
     January 01, 2024 - Keywords: Emergency Department, Blood Pressure, Maternal Care, Women Banerji A , Blumenthal … Middleton A Longitudinal investigation of rehospitalization patterns in spinal cord and traumatic brain injury … Longitudinal investigation of rehospitalization patterns in spinal cord and traumatic brain injury among … Keywords: Hospital Readmissions, Medicare, Brain Injury, Injuries and Wounds Pagination

383. Treatment Strategies for Patients with Lower Extremity Chronic Venous Disease (LECVD) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/lecvd_protocol.pdf
     March 07, 2016 - venous segment; typically classified as (a) primary/idiopathic, (b) secondary (typically due to trauma … post-thrombotic, trauma) Ap Perforator Pr,o Reflux and obstruction C3 Edema En No venous cause … and stratification based on symptom status, presence of wounds … "[Mesh] OR "Wounds and Injuries/therapy"[Mesh] OR "Negative-Pressure Wound Therapy"[Mesh] OR "Skin Care … venous wounds

384. Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/studies/index.html?page=471
     January 01, 2024 - Makic MB A framework of quality improvement interventions to implement evidence-based practices for pressure … A framework of quality improvement interventions to implement evidence-based practices for pressure ulcer … Adv Skin Wound Care 2014 Jun;27(6):280-4; quiz 85-6. doi: 10.1097/01.ASW.0000450703.87099.5b.. … Keywords: Quality Improvement, Patient Safety, Evidence-Based Practice, Pressure Ulcers, Guidelines … Keywords: Hospital Discharge, Injuries and Wounds, Elderly Edelson DP , Yuen TC , Mancini

385. National Strategy for Quality Improvement in Health Care (continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/workingforquality/about/agency-specific-quality-strategic-plans/nqs2.html
     November 01, 2016 - people and communities need to protect their health—through health promotion; prevention of disease, injury … improvement initiatives to standardize and improve the delivery of care for patients with high blood pressure … improvement initiatives to standardize and improve the delivery of care for patients with high blood pressure … improvement initiatives to standardize and improve the delivery of care for patients with high blood pressure … improvement initiatives to standardize and improve the delivery of care for patients with high blood pressure

386. Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/studies/index.html?page=391
     January 01, 2024 - organ failure score to predict post-injury multiple organ failure. … The objective of the study was to externally validate the Denver Emergency Department (ED) Trauma Organ … Failure (TOF) Score, a 6-item instrument that includes age, intubation, hematocrit, systolic blood pressure … Validation of the Denver emergency department trauma organ failure score to predict post-injury multiple … Keywords: Emergency Department, Trauma, Decision Making, Risk, Injuries and Wounds Scally CP

387. Final Progress Report: Using an Electronic Health Record to Examine Nurse Continuity and Pressure Ulcers (pdf file)
     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.

388. Final Progress Report: Pediatric Emergency Assessment Tool (pdf file)
     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.

389. AHRQ National Scorecard on Hospital-Acquired Conditions: Updated Baseline Rates and Preliminary Results 2014-2016 (pdf file)
     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

390. On World Patient Safety Day, AHRQ Highlights the Urgent Need to Address Diagnostic Safety | Agency for Healthcare Research and Quality
     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

391. Final Progress Report: Using an Electronic Health Record to Examine Nurse Continuity and Pressure Ulcers (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/23072-Stifter-draft-1.pdf
     March 02, 2015 - 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.

392. Appendix B: Trends in Access, Quality and Disparities for Measures in 2016 Report | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/nhqdr16/appendixb4_qualitytrends.html
     June 01, 2018 - complications of care during hospitalization, ages 18-89 or obstetric admissions 6.869 4.856 2014 Birth trauma-injury … pneumothorax per 1,000 medical and surgical admissions, age 18 and over -10.526 -4.472 2014 Birth trauma-injury … surgical admissions who were not susceptible to falling, age 18 and over -26.667 -2.828 2014 Birth trauma-injury … had an adverse drug event with hypoglycemic agents, age 18 and over 6.470 0.218 2014 Birth trauma-injury … 4 or more days, age 18 and over 26.654 4.548 2014 Home health care patients whose surgical wound

393. Chapter 4. Long Term Management | Agency for Healthcare Research and Quality
     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.

394. Outcomes by HCBS Participant Characteristics | Agency for Healthcare Research and Quality
     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.

395. Standardized infection ratios for central line-associated bloodstream infections and surgical site infections, 2009–2012
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/healthyliving/qdr2015-chartbook-healthyliving.pptx
     January 01, 2020 - Nerve injury not elsewhere classified at birth, and Birth trauma not elsewhere classified.24 Many … of these injuries to neonates may be preventable.25 41 Birth trauma—injury to neonate per 1,000 … Overall Rate: In 2013, the birth trauma-neonatal injury rate was 1.9 per 1,000 live births. … Between 2004 and 2013, birth trauma-neonatal injury rates fell for all racial/ethnic groups, except for … Birth Trauma Rate—Injury to Neonate: Technical Specifications.

396. Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/studies/index.html?page=345
     January 01, 2024 - Keywords: Surgery, Healthcare-Associated Infections (HAIs), Adverse Events, Injuries and Wounds, Hospitals … Safety, Healthcare Delivery Sohn MW , Epstein N , Huang ES Visit-to-visit systolic blood pressure … This study examined the relationship between systolic blood pressure (SBP) variability and the risk of … Visit-to-visit systolic blood pressure variability and microvascular complications among patients with … Keywords: Blood Pressure, Diabetes, Risk, Chronic Conditions Nguyen OK , Makam AN , Clark

397. Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/studies/index.html?page=233
     January 01, 2024 - (EDs) with a triage blood pressure (BP) of >= 120/80 mmHg and no history of hypertension. … Emergency department-provided home blood pressure devices can help detect undiagnosed hypertension. … Keywords: Blood Pressure, Emergency Department, Diagnostic Safety and Quality Xiao Y , Abebe … Surgery, Children/Adolescents, Healthcare-Associated Infections (HAIs), Patient Safety, Risk, Surgery, Injuries … and Wounds Arbaje AI , Hughes A , Werner N Information management goals and process failures

398. FileNewTemplate
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module5.pptx
     January 01, 1995 - or unfolding error An opportunity to interrupt or correct an action or event before there is harm or injury … It allows for one to take steps to interrupt or correct an action or event before there is harm or injury … Are the blood pressure cuffs, otoscope, and ophthalmoscopes working properly? … Are things being left undone because of time pressure?

399. Mod5-Case-Scenarios (pdf file)
     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

400. AHRQ Patient Safety Tools and Resources (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/resources/Patient-Safety-Tools-flyer-June2022.pdf
     May 01, 2022 - approaches to design that target six areas of safety: infections, falls, medication errors, security, injuries … //ahrq.gov/preventingfalls http://ahrq.gov/fallprevtraining http://ahrq.gov/vtguide 5 Preventing Pressure … Web: ahrq.gov/pressureulcertoolkit ■ Pressure Injury Prevention in Hospitals Training Progam supports … the training of hospital staff on how to implement AHRQ’s Preventing Pressure Ulcers in Hospitals Toolkit … injury prevention.