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161. Draft Final Report Estimating the Additional Hospital Inpatient Cost and Mortality Associated with Selected Hospital Acquired Conditions (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/hac-cost-report2017.pdf
     November 01, 2017 - Pressure Ulcers A new pressure ulcer developed during a stay, or Stage 1 or 2 pressure ulcer(s) present … , Closed"[Mesh] OR "Craniocerebral Trauma"[Mesh] OR "Cerebrovascular Trauma"[Mesh] OR "Cerebrovascular … Tissue Injury” [tiab] OR “Pressure Ulcer” [MeSH] OR “Pressure Ulcer” [tiab] OR “osteomyelitis” [MeSH … Ostomy/wound Mgmt. 2016 Nov;62(11):30. d Weiser TG, Semel ME, Simon AE, et al. … Ostomy Wound Manage. 2016 Nov;62(11):30-8. 65 Mendizabal A, Thibault DP, Willis AW.

162. Don’t Bite Your Tongue. | PSNet
     psnet.ahrq.gov/web-mm/dont-bite-your-tongue
     September 18, 2024 - Changes in motor evoked potentials can indicate an impending neurologic injury and should trigger an … Dental injury associated with anesthesia: a report of 161,687 anesthetics given over 14 years.  … Airway injury during anesthesia: a closed claims analysis.  … Cost analysis of intubation-related tracheal injury using a national database.  … August 1, 2010 WebM&M Cases Under Pressure: Delayed

163. Interim Update on 2013 Annual Hospital-Acquired Condition Rate (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/interimhacrate2013_0.pdf
     October 27, 2014 - MPSMS (2013) In-Hospital Patient Falls 240,000 7.2 Obstetric Adverse Events PSI (2012) OB Trauma … Fall and injury prevention (Chapter 10). In: Hughes RG, ed. … Preventing falls and eliminating injury at Ascension Health. … The road to zero preventable birth injuries. … Eliminating birth trauma at Ascencion Health.

164. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency | PSNet
     psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hypertensive-emergency
     May 01, 2018 - hypervolemia, leading to mismanagement of her hypertensive emergency, irreversible progression of cardiac injury … patients first present to the ED. 1 The presence of pulmonary edema with hypoxemia and acute kidney injury … with an especially elevated diastolic pressure. … nitroglycerin (given that nitroprusside is relatively contraindicated in the setting of acute kidney injury … treating hypertensive emergencies, choosing appropriate antihypertensives for patients with end-organ injury

165. Electronic Reports | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/ereports.html
     December 01, 2017 - This report is helpful for nursing home staff and wound nurses to promote early identification of pressure … These details are available at the time the pressure ulcer is being assessed during wound rounds or during … Information that displays on the Weekly Pressure Ulcer Treatment Summary Report, the Weekly Wound Rounds … Uses DON or ADON, Nurse Manager, Wound Nurse, QI Director Root Cause Analysis for New Pressure … Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance

166. Statistical Brief #130: Emergency Department Visits and Inpatient Hospital Stays for All-Terrain-Vehicle-Related Injuries, 2009 (pdf file)
     hcup-us.ahrq.gov/reports/statbriefs/sb130.pdf
     March 01, 2012 - Introduction All-terrain vehicles (ATVs) are small open motorized vehicles designed with large low-pressure … Annual Report of ATV-Related Deaths and Injuries. … Journal of Trauma-Injury Infection and Critical Care 69(6): 1344–1349. 5 Aitken, M. E., C. J. … ED visits for ATV injuries were more likely to occur on a weekend than the total of other injury-related … Compared with all injury related visits, those for ATV injuries were more likely to be covered by private

167. Archived: Final Research Plan: Preeclampsia: Screening | United States Preventive Services Taskforce
     www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan109/preeclampsia-screening-april-2017
     August 14, 2014 - How effectively do screening tests (e.g., blood pressure, proteinuria) identify women with preeclampsia … Preeclampsia risk assessment and screening KQs 1, 4, 5: Screening tests for preeclampsia (e.g., blood pressure … information obtained from patient history or measurements routinely collected in primary care (e.g., blood pressure … health outcomes (KQ 1): Maternal mortality and serious morbidity (e.g., organ or system failure or injury … neonatal mortality and serious morbidity (e.g., intrauterine growth restriction, low birthweight, brain injury

168. Estimating the economic cost of nurse sensitive adverse events amongst patients in medical and surgical settings. | PSNet
     psnet.ahrq.gov/issue/estimating-economic-cost-nurse-sensitive-adverse-events-amongst-patients-medical-and-surgical
     July 11, 2018 - Some adverse events are sensitive to aspects of nursing care , including pressure injuries , falls, … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review. … room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure

169. QDR 2014: Chartbook for Hispanic Health Care, Part 2 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2014chartbooks/hispanichealth/2014nhqdr-hispanichealth-pt2.pdf
     July 01, 2015 - - injury to newborn per 1,000 live births Better No Change Obstetric trauma per 1,000 vaginal deliveries …  Trends: ■ Birth trauma-neonatal injury rates fell from 2.6 per 1,000 live births in 2004 to 1.9 … ■ Between 2004 and 2012, birth trauma-neonatal injury rates fell for all racial/ethnic groups. … Birth trauma—injury to neonate per 1,000 live births, by race/ethnicity, 2004-2012 Key: API = Asian … 2011 2012 R at e p e r 1 ,0 0 0 L iv e B ir th s Total White Black API Hispanic Birth trauma—injury

170. Examples of Patient Harm Related to Invasive Devices | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/phys-championsgd/section3.html
     October 01, 2015 - Teamwork and Communication Definitions and Tools Several examples of severe patient injury … Paraplegia (inability to walk) Ultimately, the patient underwent back surgery to decompress the pressure … The virulent organism caused a severe infection and irreversible injury to the patient. … She was found to have a fever of 102 °F, and her blood pressure dropped to 90 systolic.

171. On-Time Preventable Hospital and ED Visits Functional Specs (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevhospitalvisits-funcspecs_0.pdf
     August 01, 2017 - Ulcer Vendor determined or Wound Assessment Pressure ulcer Stage II, III, IV, or unstageable. … IF wound assessment date ≤7 days of report date AND at least one pressure ulcer with ulcer stage = … then display X in Wound • Infected wound or decubitus ulcer • Jaundice • Rash 10 Injury: Fall … X in Injury: 11 Injury: Non- Fall Related Transfer Note • • Major injury Minor injury IF …  Chest pain/angina  Dizzy/lightheaded Non-Fall-Related Injury  Major injury  Minor injury

172. Hospitalizations for Circulatory System Disorders, 2004 (pdf file)
     hcup-us.ahrq.gov/datainnovations/clinicaldata/ExampleofUsingPOA-CMSHACsusingall-payerdata.pdf
     July 01, 2011 - The second most common CMS HAC examined was falls or trauma, which accounted for another 20 percent … (75 percent), catheter- associated urinary tract infections (72 percent), and stage III and IV pressure … For example, those 85 years and older had nearly six times the rate of CMS HACs for falls and trauma … Ulcers are: • 707.23, pressure ulcer, stage III • 707.24, pressure ulcer, stage IV The ICD-9-CM … • 830-839.99, dislocation • 850-854.99, intracranial injury • 925-929.99, crushing injury •

173. Improvement in patient safety may precede policy changes: trends in patient safety indicators in the United States, 2000-2013. | PSNet
     psnet.ahrq.gov/issue/improvement-patient-safety-may-precede-policy-changes-trends-patient-safety-indicators-united
     November 01, 2017 - The authors discuss major CMS payment policy changes and their intersection with the PSI; except for pressure … injuries, the implementation of payment policy reforms did not precede the decline trends in PSI rates … August 10, 2022 Complexity bias in the prevention of iatrogenic injury: why specific … May 13, 2020 Assessment of nursing home reporting of major injury falls for quality measurement

174. Sports-Related Emergency Department Visits and Hospital Inpatient Stays, 2013 (pdf file)
     hcup-us.ahrq.gov/reports/statbriefs/sb207-Sports-Hospital-Emergency-Department-2013.pdf
     January 01, 2013 - Control and Prevention.2 Sports and recreation-related injuries are a common type of injury seen … (18 percent), and open wounds (12 percent). … Other common, specific types of injuries included open wounds (12 percent) and intracranial injuries … Sprain 24% Fracture 21% Superficial Injury 18% Open Wound 12% Intracranial Injury 5% Other … Open wound Intracranial injury Other injury Other diagnosis Specific Sports Activity b c 12

175. Network of Patient Safety Databases Chartbook, 2019 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2019.pdf
     January 01, 2019 - event type; and, detailed information about specific event types, such as the distribution of various injuries … pertaining to nine patient safety event types that represent the majority of reported preventable injuries … Event-Specific Formats pertain to nine patient safety events that represent the great majority of preventable injuries … that they represent minor injuries such as soreness, bumps, and minor abrasions. … unstageable A lesion that, on admission, was a suspected Deep Tissue Injury A pressure ulcer at stage

176. Evaluation of AHRQ's On-time Pressure Ulcer Program - 2011 | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/evaluation-ahrqs-time-pressure-ulcer-program/annual-summary/2011
     January 01, 2011 - Evaluation of AHRQ's On-time Pressure Ulcer Program - 2011 Project Name Evaluation … of AHRQ's On-time Pressure Ulcer Program Principal Investigator Hurd, Donna Organization … Project Period June 2009 - January 2012 AHRQ Funding Amount $1,699,797 Summary: Pressure … Although substantial research has documented that preventing pressure ulcers and falls is possible, these … Information on pressure ulcer incidence provided by the facilities for a 12-month period and adjusted

177. Outcomes | Agency for Healthcare Research and Quality
     www.ahrq.gov/topics/outcomes.html
     Hospital Reduces Emergency Wait Time, Adverse Events Using AHRQ Tools Connecticut Hospital Reduces Pressure … Injuries Using AHRQ Toolkit Georgetown University Family Nurse Practitioner Program Trains Hundreds

178. Putoolssect7 (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressureulcertoolkit/putoolssect7.docx
     February 16, 2011 - Pressure ulcers are sterile wounds. 36. … Pressure ulcers are sterile wounds. False 36. … If a skin disruption is found, the type of skin injury will need to be identified. … For example is it a skin tear, a pressure ulcer, or moisture-associated skin damage or injury? … unit staff for pressure ulcer practice Certified Wound Care Nurse · Assesses wounds, does complex

179. Summary of USPSTF Final Recommendation: Interventions to Prevent Falls in Community-Dwelling Older Adults (pdf file)
     www.uspreventiveservicestaskforce.org/home/getfilebytoken/Xm5_jgUrXXGAJe8WJh_9KK
     June 01, 2024 - initial assessment of modifiable risk factors for falls (eg, balance, gait, vision, postural blood pressure … Falls are the leading cause of injury-related morbidity and mortality among older adults in the US. … adults 65 years or older reported at least 1 fall in the past year and 10.2% reported a fall- related injury … In 2021, 38,742 deaths resulted from fall-related injuries. … • The CDC’s STEADI (Stopping Elderly Accidents, Death, and Injuries) initiative helps reduce fall

180. Chartbook on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2020.pdf
     January 01, 2020 - pertaining to nine patient safety event types that represent the majority of reported preventable injuries … captures the specific type of physical injury sustained in the fall as TYPE OF INJURY AS RESULT OF … that they represent minor injuries such as soreness, bumps, and minor abrasions. … and the type of the injury. … unstageable A lesion that, on admission, was a suspected Deep Tissue Injury A pressure ulcer at stage