-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-harms.pdf
August 01, 2025 - Procedural harm and in-facility injury prevention also includes
the development of resources and tools … Using Tools and Toolkits to Prevent Procedural Harms and In-Facility Injuries
Examples of projects that … ■ Improve patient outcomes (e.g., reduced pressure injuries, infection rates, falls). … , and pressure injuries compared
to normal weight. … (fall and pressure injury prevention) to improve
patient safety.
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/050-dec-implementation-notes.docx
October 01, 2024 - A downloadable copy of this chart is available here: Action Chart for Implementing Decolonization. … , and stage 1 and 2 pressure injuries. … skin, or pressure injuries. … injuries (stage 1 and 2), superficial wounds, and sutured or stapled wounds. … CHG is approved as a wound cleanser.
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-measure-implementation.pdf
August 01, 2025 - ■ Tools and Interventions: Created innovative adverse event-prevention tools and safety systems for … Score (AIS)=5 head injury, other AIS=5 injury, or higher
age groups. … of this system allowed
data generated by MPSMS to have a large national randomly selected set of
charts … infarction, asthma, and dislocations requiring
procedural sedation; dual physician review data for 1,564 charts … than
patients without a medical injury.
-
www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
December 01, 2017 - reengineer the system to catch holes before they line up, and end system gaps that lead to a patient injury … On the way out of the ICU, the nurse handed over the chart with the Kardex stamp plate. … It’s tough when the pressure is high and the patient is at risk. … Use a flip chart, a chalkboard, or a whiteboard, or tape oversized paper to the wall. … Outline your data collection and audit plans: the frequency of the collection or the audit and the sample
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects.pptx
December 01, 2017 - What tools or technologies were used and how? … reengineer the system to catch holes before they line up, and end system gaps that lead to a patient injury … It’s tough when the pressure is high and the patient is at risk. … Then, you tweak the intervention and audit again. … Outline your data collection and audit plans: the frequency of the collection or the audit and the sample
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-0232-fullreport.pdf
February 01, 2020 - Markers of vascular injury can be detected in very young children, demonstrating that the path to
cardiovascular … In total, 600 charts were reviewed. … obesity: more
complete and accurate data with fewer errors, cost-effectiveness, use of online assessment tools … Height, weight, and blood pressure were
sometimes missing from the chart, and there could be substantial … Limitations for this measure
include missing chart values for height, weight, and/or blood pressure,
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
December 01, 2017 - reengineer the system to catch holes before they line up, and end system gaps that lead to a patient injury … On the way out of the ICU, the nurse handed over the chart with the Kardex stamp plate. … It’s tough when the pressure is high and the patient is at risk. … Use a flip chart, a chalkboard, or a whiteboard, or tape oversized paper to the wall. … Outline your data collection and audit plans: the frequency of the collection or the audit and the sample
-
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. … 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 … Provider order for wound care on the chart within 24 hours of notification
j.
-
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.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressureulcertoolkit/putoolssect7.pdf
January 01, 2004 - Preventing Pressure Ulcers in Hospitals: A Toolkit - Section 7, Tools and Resources
Section 7. … Pressure ulcers are sterile wounds.
36. … Pressure ulcers are sterile wounds. False
36. … For example is it a skin tear, a pressure ulcer, or
moisture-associated skin damage or injury? … Provider order for wound care on the chart within 24 hours of notification
j.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_opt_briefings.pptx
December 01, 2017 - Serious injury specifically includes loss of limb or function. … Review the perfusion plan, including cannulation, perfusion pressure goals, temperature, and transfusion … The surgical audit tools will also identify system flaws. … The checklist does not remain with the chart, but stays in the department. … for improvement
Ask if instrument, sponge, and needle counts are correct
Record name of procedure and wound
-
www.ahrq.gov/sites/default/files/2024-07/buckley-report.pdf
January 01, 2024 - Organizational Charts of All NEH entities
5. Major NEH Initiatives, written September 2004
6. … Fully Implement CPOE with Clinical Decision
Support
Reduce LOS Through Full Use of Automated
Tools … movement is multifaceted and complex, embracing a range of perspectives on the
etiology of patient injuries … Such pressures may be the stimulus for
beneficial innovation, as necessity spawns invention, and traditional … implementation
The fields of Human Computer Interaction and Human Factors have developed methods
and tools
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/049-dec-implementation-slides.pptx
October 01, 2024 - and Dressings8
Recommended for superficial wounds
Friable skin/rashes
Superficial burns
Pressure injuries … Recent nasal surgery or trauma:
Discuss with your hospital’s ENT surgeons to establish guidelines for … CHG is approved as a wound cleanser. … Encourage wound care nurses to provide support to staff who are uncomfortable. … SHIELD: Eliminating Multidrug-Resistant Organisms; FAQ: Wound Care.
-
www.ahrq.gov/hai/tools/surgery/modules/implementation/opt-briefings-fac-notes.html
December 01, 2017 - Serious injury specifically includes loss of limb or function. … Review the perfusion plan, including cannulation, perfusion pressure goals, temperature, and transfusion … The surgical audit tools will also identify system flaws. … Instead, the checklist is placed in each chart for every case, so it is consistently available when it … The checklist does not remain with the chart, but stays in the department.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_opt_briefings_facnotes.docx
December 01, 2017 - Serious injury specifically includes loss of limb or function. … Review the perfusion plan, including cannulation, perfusion pressure goals, temperature, and transfusion … The surgical audit tools will also identify system flaws. … Instead, the checklist is placed in each chart for every case, so it is consistently available when it … The checklist does not remain with the chart, but stays in the department.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/preventing-cauti-engaging-clinicians-051413.ppt
January 01, 2013 - (mechanical complications):
Metal and urethral injury
Hematuria
Hospitalists Geriatricians
Infectious … Inappropriate urinary catheter use may negatively affect the surgeon’s profile
Risk of infection and trauma … Evaluation urinary catheter need is part of daily nursing routine
Use of EMR/electronic reminders or tools … They may lead to urinary tract infections and cause mechanical trauma to the urethra and bladder. … They also immobilize patients—increasing the likelihood of pressure ulcers, falls and prolonged inpatient
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-232-fullreport.pdf
June 01, 2018 - A limited window of opportunity exists for treating underlying injury once shock is present. … Data and Methods
Measure testing involved an audit of medical records from three of the largest hospitals … hospital was reviewed as were the various locations where heart rate
may be documented within the charts … the
chart it was recorded that the dose administered was 0 mL. … The medical chart audit included
records from three of the largest hospitals serving children in Michigan
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-fullreport.pdf
April 01, 2018 - Black and Hispanic newborns are at higher risk of birth trauma
(Miller, et al., 2003). … session, experts presented findings from
these charts. … We suggest establishing a system to audit hospital GAPPS
reports if the measure is ultimately used to … Internal pressures, such as a punitive culture
that leads to underreporting of medical errors, may influence … Identifying adverse drug events: Development of a
computer- based monitor and comparison with chart
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0231-fullreport.pdf
May 01, 2018 - A limited window of opportunity exists for treating underlying injury once shock is present. … Data and Methods
Measure testing involved an audit of medical records from three of the largest hospitals … the
chart it was recorded that the dose administered was 0 mL. … The medical chart audit included
records from three of the largest hospitals serving children in Michigan … Improving outcomes for severe sepsis and septic shock: Tools for early
identification of at-risk patients
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0230-fullreport.pdf
April 02, 2018 - A limited window of opportunity exists for therapy of the underlying injury once shock is present. … Data and Methods
Measure testing involved an audit of medical records from three large hospitals serving … the
chart it was recorded that the dose administered was 0 mL. … The medical chart audit included
records from three large hospitals serving children in Michigan: Children … Improving outcomes for severe sepsis and septic shock: Tools for early
identification of at-risk patients