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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxsamplereports.pdf
June 02, 2025 - On-Time Falls Prevention: Electronic Reports
On-Time Falls Prevention: Electronic Reports
Four types of reports are described here. Each section presents a sample report followed by
purpose, description, and users and potential uses. The types of reports are:
• On-Time Falls High-Risk Report.
• Quarterly Summar…
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www.ahrq.gov/sites/default/files/2024-01/scott-report.pdf
January 01, 2024 - , Hypovolemia
Induction, Coronary Artery Disease/Congestive Heart Failure Induction, Apnea During
Sedation
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www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guide7.html
May 01, 2016 - Preventing Hospital-Associated Venous Thromboembolism
Chapter 7. Layering Interventions and Moving Toward Excellence
Previous Page Next Page
Table of Contents
Preventing Hospital-Associated Venous Thromboembolism
Preface
Executive Summary
Chapter 1. The Framework for Improvement
Chapter 2. A…
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www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide7.html
May 01, 2016 - Preventing Hospital-Associated Venous Thromboembolism
Chapter 7. Layering Interventions and Moving Toward Excellence
Previous Page Next Page
Table of Contents
Preventing Hospital-Associated Venous Thromboembolism
Preface
Executive Summary
Chapter 1. The Framework for Improvement
Chapter 2. A…
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/reportguide.html
November 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Training
Facilitator Training Instructor Guide
Slide 1: Introduction to Falls Reports
AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Facilitator Training
Introduction to Falls Reports
Say:
In this session we will in…
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www.ahrq.gov/sites/default/files/2024-01/aparasu-report.pdf
January 01, 2024 - major risk
factor for dementia. 13
Although centrally mediated anticholinergic activity can lead to sedation
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man4.html
December 01, 2017 - The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities
Chapter 4. Long Term Management
Previous Page Next Page
Table of Contents
The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities
Chapter 1. Introduction and Program Overview
Chapt…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Hougland_26.pdf
October 01, 2011 - Using ICD-9-CM Codes in Hospital Claims Data to Detect Adverse Events in Patient Safety Surveillance
Using ICD-9-CM Codes in Hospital Claims Data
to Detect Adverse Events in Patient
Safety Surveillance
Paul Hougland, MD; Jonathan Nebeker, MS, MD; Steve Pickard, MBA; Mark Van Tuinen, PhD;
Carol Masheter, PhD; Su…
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www.ahrq.gov/sites/default/files/2024-01/lannon1-report.pdf
January 01, 2024 - Period Intervention Period Pre/Baseline Period
January 2008 - Began post-anesthesia care unit
Ramsey Sedation
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www.ahrq.gov/sites/default/files/2024-07/hripcsak-report.pdf
January 01, 2024 - In one study, aspiration pneumonia in the
setting of conscious sedation, perioperative myocardial infarction
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www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
November 01, 2021 - critically ill, intubated, COVID-19 positive, in multisystem organ
failure, NSTEMI5, requiring pressors, sedation
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Graham_77.pdf
March 05, 2008 - Nifedipine 1 moderate Fair
Increased risk
of nifedipine
side effects
Trazodone 1 MAJOR Poor
Excessive
sedation
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www.ahrq.gov/sites/default/files/2025-02/griffey-report.pdf
January 01, 2025 - efforts on GTT-identified AEs related to hypoglycemia,
VTE prophylaxis and analgesia-related over-sedation … 1.06% 101 21.8% 115 22.6%
M6 Peripheral pressor administration 0.29% 42 21.4% 34 44.1%
P4 Procedural sedation
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-care-coordination.pdf
June 30, 2025 - Key Findings/Impact: A sedation risk screening tool for patients was finalized
but not made available … identify risk, actual
resource allocation, and provider behavior that increase risk during procedural
sedation
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www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/pu3.html
October 01, 2014 - Chemical restraints with resulting sedation may lead to rapid decline in mobility.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Singh-R_68.pdf
April 20, 2008 - accurate information about:
Unable to explain pain due to language barrier
Unable to explain pain due to sedation
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kleinpeter.pdf
January 01, 2004 - anesthesia administered in the clinics include
anxiolysis, local and regional anesthesia, moderate and deep sedation
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Seger.pdf
January 01, 2003 - HMG-CoA reductase inhibitors AND myopathy
Amiodarone AND thyroid abnormality
Antipsychotic agents AND sedation
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu3.html
October 01, 2014 - Chemical restraints with resulting sedation may lead to rapid decline in mobility.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/ambulatory-surgery-report.pdf
May 01, 2017 - Colon/bowel issue 3
Intractable nausea/vomiting 3
Fever 2
Failure to void 2
Allergic reaction 1
Sedation-related … Nineteen unplanned intervention events reported a “sedation-related issue.” … content areas of surgical safety checklist use, teamwork and communication, scope
processing, and sedation … 74%
0%
20%
40%
60%
80%
100%
Use of the Checklist Teamwork and
Communication
Scope Processing Sedation