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381. AHRQ Quality Indicators Prioritization Worksheet Example (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.pdf
     June 02, 2025 - 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

382. Evaluation of AHRQ’s On-Time Pressure Ulcer Program - 2012 | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/evaluation-ahrqs-time-pressure-ulcer-program/annual-summary/2012
     January 01, 2012 - Evaluation of AHRQ’s On-Time Pressure Ulcer Program - 2012 Project Name Evaluation … of AHRQ's On-time Pressure Ulcer Program Principal Investigator Hurd, Donna Organization … Although substantial research has documented that preventing pressure ulcers and falls is possible, these … In response, AHRQ funded a rigorous evaluation of the On-Time Pressure Ulcer program. … A training curriculum for the On-Time Pressure Ulcer program was developed and tested.

383. Spotlight Case July 2008 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.197_slideshow.ppt
     April 01, 2009 - pubmed/8333382 * PICCs Can Cause Complications In retrospective series, complications included: Wound … vessel wall, increasing chance of breakage on removal Small syringe used for flushing creates higher pressure … increased stress on catheter * Recommendations for Prevention Avoid flushing PICCs under high pressure … has become increasingly prevalent, including in pediatric inpatients PICC complications include: Injury … fractures Caregivers should be warned against flushing PICCs with small-volume syringes or with too much pressure

384. 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 •

385. Outcome Indicators for the HCBS Population | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/find4.html
     December 01, 2012 - All but two of the indicators (Pressure Ulcer and Injurious Falls) build on existing AHRQ Prevention … Pressure Ulcer. Injurious Falls.

386. NICU Family Information Packet, Appendix B, Ostomy Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-ostomy.pdf
     June 02, 2025 - anchoring elements to bond the epidermis to the underlying dermis, so skin is more susceptible to friction injury … ■ Peristomal skin must be protected from mechanical trauma due to use of aggressive adhesives, improper … ■ Vent frequently to prevent gas pressure from compromising the seal.

387. Harm Free Care. | PSNet
     psnet.ahrq.gov/issue/harm-free-care
     April 15, 2020 - This initiative seeks to reduce four key sources of harm in hospitals: pressure ulcers, falls, catheter-associated … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

388. Patient safety indicators during the initial COVID-19 pandemic surge in the United States. | PSNet
     psnet.ahrq.gov/issue/patient-safety-indicators-during-initial-covid-19-pandemic-surge-united-states
     August 03, 2022 - September 1, 2021 Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence. … About The Topic Hospitals Public Health Infectious Diseases Medical Complications Pressure

389. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits Training | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereportguide.html
     September 01, 2017 - Infected wound or decubitus. Jaundice. Rash. Fall-Related Injury. … Wound or skin issues. Fall-related injury. Non-fall-related injury. Abnormal labs. … Fall/trauma. Anemia. Diabetes. … Wound or skin issues. Fall-related injury. Non-fall-related injury. Abnormal labs. … Fall/trauma. Anemia. Diabetes.

390. Declines in Hospital-Acquired Conditions (pdf file)
     www.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

391. Nosy Business | PSNet
     psnet.ahrq.gov/web-mm/nosy-business
     March 01, 2007 - , including self-induced "digital trauma." … Similar to bleeding from other sites, it is most effectively controlled by direct pressure. … Not only do these injuries create additional bleeding sources, they are commonly mistaken for the original … septum to avoid a septal perforation.( 5 ) Moisturizing the nasal cavity is important while the cautery wound … December 1, 2012 WebM&M Cases Missing the Point—Eye Injury

392. Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx (pdf file)
     psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
     January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx Spotlight … Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy … staggering racial and ethnic disparities in maternal morbidity and mortality. 3 UTERINE ARTERY INJURY … survived, she suffered another cardiac arrest with residual cognitive impairment. 8 UTERINE ARTERY INJURY … rate >24 or <10/minuteRespiratory rate Systolic >155 or <80 mm Hg Diastolic >105 or <45 mm Hg Blood pressure

393. Microsoft Word - Comp Eff 10.doc (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/pdf/ace-inhibitor-arb-2007_research-2007-1.pdf
     January 01, 2007 - hypertension are not on treatment, and two-thirds of hypertensive patients continue to have blood pressures … - When used in pregnancy during the second and third trimesters, ACEIs can cause injury and even … - When used in pregnancy during the second and third trimesters, ACEIs can cause injury and even … - When used in pregnancy during the second and third trimesters, ACEIs can cause injury and … Blood pressure control?

394. The impact of the use of employee functional flexibility on patient safety. | PSNet
     psnet.ahrq.gov/issue/impact-use-employee-functional-flexibility-patient-safety
     January 12, 2022 - examined the effect of unit-level nursing functional flexibility on the incidence of hospital-acquired pressure … Results indicate that higher use of functionally flexible nurses was associated with a higher number of pressure … Implementing an electronic root cause analysis reporting system to decrease hospital-acquired pressure … injuries.

395. Table 14A: Outcome Indicators by County Supply of Health Care Providers | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab14.html
     February 01, 2023 - 7,561 7,177 Composite: ACSC Overall 19,494 19,068 22,370 17,903 19,831 18,937 Pressure … 8,666 8,172 Composite: ACSC Overall 21,480 21,331 24,806 19,795 22,008 20,929 Pressure … 4,449 4,235 Composite: ACSC Overall 13,871 12,234 15,225 12,474 13,703 13,045 Pressure … 3,525 3,189 Composite: ACSC Overall 5,684 5,096 5,763 5,286 5,764 5,235 Pressure … 10,552 Composite: ACSC Overall 25,931 27,847 34,209 23,478 26,582 26,462 Pressure

396. Appendix C. Sample Search Strategies | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/engage/appc.html
     March 01, 2017 - ti])) OR iatrogenesis [ti] OR iatrogenic [ti] OR ((medical [ti] OR treatment [ti] OR care [ti]) AND (injury … [ti] OR injuries [ti])) OR mishap* [ti] OR (root [ti] AND cause* [ti]) OR (failure* [ti] AND mode* [ … reducing [ab] OR reduction [ab] OR aged [mh] OR elderly OR geriatric)) OR Decubitus Ulcer [mh] OR ((pressure

397. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/846169/psn-pdf
     March 15, 2023 - young patients because their strong chest wall muscles can create much higher negative intrathoracic pressures … Succinylcholine is contraindicated in patients with stroke, spinal cord injury, burns, or myotonic dystrophy … inadequate resources such as the broken drug refrigerator otherwise could have led to irreversible injury … Risk of respiratory complications and wound infection in patients undergoing ambulatory surgery: smokers … Negative-pressure pulmonary edema. Chest. 2016;150(4):927-933. [Available at] 14.

398. Case studies on medication reconciliation. | PSNet
     psnet.ahrq.gov/issue/case-studies-medication-reconciliation
     February 15, 2023 - June 9, 2021 Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence.

399. Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach. | PSNet
     psnet.ahrq.gov/issue/multimethod-study-large-scale-programme-improve-patient-safety-using-harm-free-care-approach
     January 23, 2019 - improvement project in the United Kingdom to address four patient safety issues: venous thromboembolism , pressure … August 5, 2020 Towards international consensus on patient harm: perspectives on pressure … injury policy.

400. Adverse events experienced by homecare patients: a scoping review of the literature. | PSNet
     psnet.ahrq.gov/issue/adverse-events-experienced-homecare-patients-scoping-review-literature
     October 19, 2022 - Categories included adverse drug events and line-related problems as well as the expected focus on wounds … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.