-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/14295%20Shenep-draft-1.pdf
June 01, 2005 - Review
effectiveness
of 60%.
6 Significant
effect/
Minor injury
Actual error
occurred and
reached … Page 8
8 Extreme
effect/major
injury
Actual error
occurred and
reached the
patient. … Error
would result
in a major
injury for the
individual
served,
including
permanent
patient harm … detect
Remote
likelihood that
current
controls will
detect.
10 Catastrophic
effect;
terminal
injury … Discussion
Although CPOE is supported philosophically by multiple groups that exert significant pressure
-
www.ahrq.gov/sites/default/files/2024-01/shenep-report.pdf
January 01, 2024 - Review
effectiveness
of 60%.
6 Significant
effect/
Minor injury
Actual error
occurred and
reached … Page 8
8 Extreme
effect/major
injury
Actual error
occurred and
reached the
patient. … Error
would result
in a major
injury for the
individual
served,
including
permanent
patient harm … detect
Remote
likelihood that
current
controls will
detect.
10 Catastrophic
effect;
terminal
injury … Discussion
Although CPOE is supported philosophically by multiple groups that exert significant pressure
-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/2014-women-chartbook.pdf
January 01, 2014 - For example, only
half of people with high blood pressure have it controlled. … High blood pressure costs the Nation $46 billion each year. … mostly attributable to sudden unexpected
infant death (SUID), congenital anomalies, infection, and injury … Web-based Injury Statistics Query and Reporting System (WISQARS)
[Online]. (2013). http://www.cdc.gov … /injury/wisqars/index.html .
-
www.ahrq.gov/news/events/nac/2017-11-nac/nacmtg1117-minutes.html
February 01, 2018 - Preliminary data on the use of the training materials showed significant decreases in falls with injury … AHRQ also released training materials for preventing pressure ulcers in hospitals. … Preliminary data on use of the materials showed significant decreases in pressure ulcers during a 1-year
-
www.ahrq.gov/research/findings/nhqrdr/chartbooks/effectivetreatment/effectivetreatment-slides.html
April 01, 2018 - Most Costly Conditions, 2013
Condition
Total Expenses (Millions)
Report Section
Trauma-related … Blood pressure under control is defined as having a mean systolic blood pressure <140 and mean diastolic … blood pressure <90 among all hypertensive patients. … , blood pressure control among people with diagnosed high blood pressure remains a problem. … Increased risk of death from car crashes and other injuries.
-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/qdr2016-ptschartbook.pdf
July 19, 2017 - 60
80
100
120
140
160
2010 2011 2012 2013 2014 2015
R
at
e
1
,0
0
0
D
is
ch
a
rg
e
s
Pressure … 60
80
100
120
140
160
2010 2011 2012 2013 2014 2015
R
at
e
1
,0
0
0
D
is
ch
ar
ge
s
Pressure … ■ An ADE is an injury—including physical harm, mental harm, or loss of function—
resulting from medical … Importance: Normal wound healing after an operation is an important marker of good care. … The home health team should regularly change wound dressing and teach the patient about
wound care
-
www.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamily3a.html
July 01, 2018 - External motivation may also come from pressures or "pushes" from external organizations. … hospital-associated infections, reducing risk of harm from patient falls, and preventing hospital-associated pressure … unanticipated event in a health care setting resulting in death or serious physical or psychological injury … level (e.g., on PFACs and decisionmaking committees). 103,104
Sentinel events also lead to external pressures
-
www.ahrq.gov/sites/default/files/2025-02/silver-report.pdf
January 01, 2025 - Two
hospitalizations (1.5%) were the result of injuries that were unrelated to home care. … 120
Decline resulting from
patient's condition
Complication of earlier
care
New diagnosis Injury … benefit will be
provided in those visits (e.g., an agency cannot simply increase the frequency of wound … Identifying barriers to reporting changes in condition: unclear expectations, time/production
pressure
-
www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-pediatric-safety.pdf
September 01, 2023 - status, extremes of age, delirium, or poor
information exchange between health systems;
■ Time pressures … Identification of children at very low risk of clinically-
important brain injuries after head trauma … Cluster Randomized Trial Reducing Missed Elevated Blood
Pressure in Pediatric Primary Care: Project … Disparities in the evaluation and
diagnosis of abuse among infants with traumatic brain injury. … The use of telemedicine in the care of the pediatric trauma patient. Semin
Pediatr Surg.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_opt_briefings_facnotes.docx
December 01, 2017 - defines a sentinel event as an unexpected occurrence involving death or serious physical or psychological injury … Serious injury specifically includes loss of limb or function. … Review the perfusion plan, including cannulation, perfusion pressure goals, temperature, and transfusion
-
www.ahrq.gov/hai/tools/surgery/modules/implementation/opt-briefings-fac-notes.html
December 01, 2017 - defines a sentinel event as an unexpected occurrence involving death or serious physical or psychological injury … Serious injury specifically includes loss of limb or function. … Review the perfusion plan, including cannulation, perfusion pressure goals, temperature, and transfusion
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/perinatal/chipra-0082-fullreport.pdf
March 01, 2016 - delivery are at much higher risk for rehospitalization for uterine infection
and obstetrical surgical wound … nonmedical
factors such as provider density, the capacity of the local health care system, and malpractice
pressure … o Have a physical abnormality or injury to their brain or spinal cord. … For example, there may be fewer surgical injuries and fewer infections. … vaginally is more likely to have a nerve injury that affects the shoulder, arm, or
hand.
-
www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-2/guide.html
September 01, 2017 - applied to other quality improvement efforts in a hospital, such as preventing:
Hospital-acquired pressure … injuries.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module2/module2_fall-prevention.docx
August 24, 2017 - applied to other quality improvement efforts in a hospital, such as preventing:
Hospital-acquired pressure … injuries.
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-medication-safety.pdf
September 30, 2024 - ■ To reduce medication-associated acute kidney injury in nine pediatric hospitals, one project
disseminated … Neither intervention affected blood pressure control. … Participating in a learning
network that required all participants to implement Nephrotoxic Injury Negated … enforcement actions (e.g., increased borrowing behavior to avoid citations
for “drug not available,” time pressures … analgesics was most common among
children with outpatient procedures, dental procedures, traumatic injuries
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Pratt.pdf
March 01, 2004 - The usual time
Advances in Patient Safety: Vol. 4
36
pressures and competing demands kept early … identification and wrong-site surgery; (3) event
reporting, including near misses; and (4) physical injury … As the collaborative and Consortium have grown, there has been increasing
pressure to take on new initiatives
-
www.ahrq.gov/sites/default/files/2025-02/weekes-report.pdf
January 01, 2025 - important indicator of acute PE of moderate to high severity is an acute increase in right
ventricular pressure … abnormality is commonly assessed in two ways: 1) laboratory surrogates of myocardial stretch
and injury … and 2) imaging assessments for RV dilatation, pressure increases, and decreased
systolic function. … point each for abnormal RV by
echocardiography, abnormal RV by computed tomography, systolic blood pressure
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/icu-clinical-decision-making-transcript.docx
January 01, 2015 - Are you a medical, a surgical, a cardiothoracic, coronary, other such as the neuro critical care, trauma … an indwelling urinary catheter related to the use of paralytics, sedative, hypnotics or orthopedic trauma … 10:00 o’clock your patient is unsedated on [inaudible 00:29:16] fall they have a catheter but their injury … I’m specifically asking about the evidence for that and the potential complications, pressure alters … We have worked with our pressure alter team to look at skin breakdown prevention.
-
www.ahrq.gov/hai/cauti-tools/archived-webinars/icu-clinical-decision-making-transcript.html
December 01, 2017 - Are you a medical, a surgical, a cardiothoracic, coronary, other such as the neuro critical care, trauma … an indwelling urinary catheter related to the use of paralytics, sedative, hypnotics or orthopedic trauma … 10:00 o'clock your patient is unsedated on [inaudible 00:29:16] fall they have a catheter but their injury … I'm specifically asking about the evidence for that and the potential complications, pressure alters … We have worked with our pressure alter team to look at skin breakdown prevention.
-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/effectivetreatment/qdr2015-chartbook-effective.pptx
September 06, 2016 - United States.
12
Most Costly Conditions, 2013
Condition Total Expenses (Millions) Report Section
Trauma-related … Blood pressure under control is defined as having a mean systolic blood pressure <140 and mean diastolic … blood pressure <90 among all hypertensive patients. … , blood pressure control among people with diagnosed high blood pressure remains a problem. … Increased risk of death from car crashes and other injuries.
118
Importance of Treatment
In 2011