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41. References | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/hai/pfp/hacrate2013-refs.html
    October 01, 2015 - Injury From Falls Barrett JA, Bradshaw M, Hutchinson K, et al. … Fall and injury prevention (Chapter 10). In: Hughes RG, ed. … Preventing falls and eliminating injury at Ascension Health. … Eliminating birth trauma at Ascencion Health. Jt Comm J Qual Patient Saf 2007;33:15-24. … Pressure Ulcers Agency for Healthcare Research and Quality.

42. C1 Prioritization Matrix (xls file)
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.xlsx
    July 01, 2016 - Patient Safety PSI 03 Pressure Ulcer   1.2 1.3 7 $109,870 $ 769,087 N 6 7 7 Y Y Y Y Y PSI 06 Iatrogenic … 13 Postoperative Sepsis 12.7 11.7 15 $49,215 $ 738,225 N 9 7 3 Y Y Y Y Y PSI 14 Postoperative Wound … Accidental Puncture or Laceration 3.2 3.3 1 $22,629 $ 22,629 Y 4 3 7 Y N Y Y Y Obstetric PSI 17 Birth Trauma-Injury … to Neonate   0.0 0.1 0 $88,000 $ - 0 N 2 3 9 Y Y Y Y Y PSI 18 Obstetric Trauma-Vaginal Delivery … Postoperative Sepsis Rate 0.0 16.2 0 $117,815 $ - 0 N 9 10 10 Y Y Y Y Y PDI 11 Postoperative Wound

43. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
    May 17, 2016 - o Decreased central nervous system input (head injury, ingestion of central nervous system depressant … o Peripheral nerve/neuromuscular junction (spinal cord injury, organophosphate/carbamate poisoning, … expansion exercises with children, such as incentive spirometry, deep breathing, intermittent positive-pressure … breathing, and continuous positive airway pressure. … Noninvasive positive pressure ventilation for acute respiratory failure in children: a concise review

44. Declines in Hospital-Acquired Conditions (pdf file)
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-rates-2019-updated.pdf
    January 01, 2019 - Conditions National efforts to reduce hospital-acquired conditions such as adverse drug events and injuries … CLABSI+ -6% Clostridioides difficile Infections -37% Falls -5% Obstetric Adverse Events -3% Pressure

45. Health Care Facility Design Safety Risk Assessment Toolkit | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/hospital/resource/safety-assess.html
    October 01, 2020 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … The toolkit: Targets six areas of safety—infections, falls, medication errors, security, injuries of

46. Appropriate Disclosure to a Patient: Video | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/hospital/candor/videos/app-disclosure.html
    August 01, 2022 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

47. Inappropriate Disclosure to a Patient: Video | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/hospital/candor/videos/inapp-disclosure.html
    August 01, 2022 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

48. Introduction to Communication and Optimal Resolution (CANDOR): Video | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/hospital/candor/videos/introduction.html
    August 01, 2022 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

49. Accountability—Peer to Peer Coaching: Video | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/hospital/candor/videos/accountability.html
    August 01, 2022 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

50. Communication and Optimal Resolution (CANDOR): Grand Rounds Presentation Video | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/hospital/candor/videos/grpresentation.html
    August 01, 2022 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

51. Planning for Meetings with Family: Video | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/hospital/candor/videos/meeting.html
    August 01, 2022 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

52. Event Investigation and Analysis Guide: Appendix B | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apb.html
    August 01, 2022 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … However, she felt pressure from senior leaders to comply with the request and did not speak up. … 0945) The CNA reports back to RN#1 the following: "Your new patient’s blood sugar was 149, the blood pressure … 0947) The CNA reports back to RN#2 the following: "Your new patient’s blood sugar was 525, the blood pressure

53. Fall TIPS: A Patient-Centered Fall Prevention Toolkit | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/hospital/fall-tips/index.html
    February 01, 2021 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … Background Falls are the most common cause of preventable injury.

54. Event Investigation and Analysis Guide: Appendix C | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apc.html
    August 01, 2022 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

55. Event Investigation and Analysis Guide: Appendix G | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apg.html
    August 01, 2022 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

56. Module 1: Preventing Falls in Hospitals—Training Guide | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-1/guide.html
    September 01, 2017 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … Between 30 and 51 percent of falls in hospitals result in an injury ranging from bruises to severe wounds … The cost of serious fall-related injuries at three Midwestern hospitals. … Thus, the CAUTI, SSI, and Pressure Injury committees used the AHRQ assessment tools, and a speak-up campaign

57. Case Scenarios: Handling Challenging Communications | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/scenarios.html
    August 01, 2022 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … 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 of

58. AHRQ Quality Indicators Prioritization Worksheet Example (pdf file)
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.pdf
    June 29, 2016 - Postoperative Sepsis 12.7 11.7 15 $49,215 $ 738,225 N 9 7 3 Y Y Y Y Y PSI 14 Postoperative Wound … - Injury to Neonate 0.0 0.1 0 $88,000 $ - N 2 3 9 Y Y Y Y Y PSI 18 Obstetric … Trauma-Vaginal Delivery With Instrument 134.8 135.1 17 $90,000 $ 1,530,000 N 2 3 8 Y Y … Y Y Y PSI 19 Obstetric Trauma-Vaginal Delivery Without Instrument 17.0 17.9 5 $96,000 $ … Rate 0.0 16.2 0 $117,815 $ - N 9 10 10 Y Y Y Y Y PDI 11 Postoperative Wound

59. SOPS Nursing Home Survey: What You Need To Know - Nicholas Castle, Ph.D., M.H.A., FGSA (pdf file)
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-nh_webcast-castle.pdf
    January 01, 2006 - Hospitals ►Moving, Transferring, or Lifting Residents ►Medication errors ►Falls ►Pressure ulcers ►Sanitation … Patient Safety Culture in Nursing Homes • Safety culture influences staff as well as residents ► Overall injury

60. Preventing Falls in Hospitals | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/index.html
    February 01, 2024 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … How do you measure fall and fall-related injury rates?     5.2.