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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.xlsx
July 01, 2016 - Trauma-Vaginal Delivery Without Instrument
Death PSI 02 Death in Low-Mortality DRGs
PSI 04 Death Among Surgical … Inpatients
Sentinel Events (Adults) PSI 05 Retained Surgical Item or Unretrieved Device Fragment … Central Venous Catheter-Related Blood Stream Infection Rate
Sentinel Events (Pediatric) PDI 03 Retained Surgical
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monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-5-26-2021.pdf
January 01, 2021 - Multiple Units, No specific unit
1 Many different hospital units,
No specific unit
Medical/Surgical … Units
2 Combined Medical/Surgical
Unit
3 Medical Unit (Non-Surgical)
4 Surgical Unit … , Behavioral
Health
13 Pulmonology
14 Rehabilitation, Physical
Medicine
15 Telemetry
Surgical
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monahrq.ahrq.gov/news/newsletters/e-newsletter/845.html
January 01, 2023 - AHRQ Grantee Prevents Harm by Analyzing and Redesigning Surgical Staff Workflows . … AHRQ Grantee Prevents Harm by Analyzing and Redesigning Surgical Staff Workflows
AHRQ’s latest grantee … His research focuses primarily on developing evidence-based strategies to prevent surgical harm using … Catchpole identified 30 sources of potential harm in surgical sterilization processes.
-
monahrq.ahrq.gov/funding/grantee-profiles/grtprofile-huang.html
December 01, 2023 - the use of targeted decolonization with routine post-discharge wound care to reduce post-discharge surgical … The Decrease SSI Trial (Decolonization to Reduce After-Surgery Events of Surgical Site Infection) project … advance the appropriate use of antibiotics for children and the use of claims data for surveillance of surgical
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monahrq.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2017-materials/teamstepps-webinar-051017.pptx
January 01, 2017 - on the benefits of TeamSTEPPS & get their support
Socialize TeamSTEPPS with Perioperative Leaders:
Surgical … Chiefs of Service
Surgical Service Managers
Anesthesia Leaders
Develop an interdisciplinary core team … Monthly Webinar
Establish the Training Mission
Train the entire service line at one time
Include all surgical … specialties & departments
Train surgeons, residents, nurses, surgical techs, and support staff together
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monahrq.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/improve/antibiotic-time-out-tool.docx
November 01, 2019 - sputum
☐ Coagulase-negative staphylococci in a single blood culture
☐ Candida in sputum or urine
☐ Surgical … medical management*
5–10 days based on clinical response15,19
Uncomplicated acute cholecystitis, surgical … management
No antibiotics after surgery23
Complicated acute cholecystitis (e.g., perforation, fistula), surgical … The Surgical Infection Society revised guidelines on the management of intra-abdominal infection.
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monahrq.ahrq.gov/hai/tools/ambulatory-surgery/how-to-use.html
May 01, 2017 - CLABSI and CAUTI Prevention in ICUs
Community-Acquired Pneumonia Toolkit
Improving Surgical … Your facility can use the materials in each section to teach team members how to apply CUSP to prevent surgical
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monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-English-05.18.21.docx
June 09, 2016 - Multiple Units, No specific unit
1 Many different hospital units, No specific unit
Medical/Surgical … Units
2 Combined Medical/Surgical Unit
3 Medical Unit (Non-Surgical)
4 Surgical Unit
Patient Care … Psychiatry, Behavioral Health
13 Pulmonology
14 Rehabilitation, Physical Medicine
15 Telemetry
Surgical
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monahrq.ahrq.gov/research/findings/studies/index.html
January 01, 2024 - This study evaluated best methods to assess surgical wire navigation skill, which can be objectively … This study investigated variability in surgical approaches to hernias in patients with ascites. … The primary outcome observed was incidence and surgical approach for both ventral and inguinal hernia … Open repair was the most common surgical approach (ventral: 86%, open: 77%). … Variability in surgical approaches to hernias in patients with ascites.
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monahrq.ahrq.gov/research/findings/making-healthcare-safer/comparison.html
September 01, 2022 - Laparoscopic Cholecystectomy
Summary of Evidence
(Not reviewed)
(Not reviewed)
Prevention of Surgical … Guidance of Central Vein Catheterization
Summary of Evidence
Update
(Not reviewed)
Prevention of Surgical … Evidence
Update
(Not reviewed)
Use of Report Cards and Outcome Measurements To Improve Safety of Surgical … Care: American College of Surgeons National Surgical Quality Improvement Program
(Not reviewed) … 2020)
Prevention of Venous Thromboembolism
Summary of Evidence
Update
(Not reviewed)
Post-Surgical
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/natlhacratereport-rebaselining2014-2016_0.pdf
January 01, 2016 - conditions (acute myocardial infarction
[AMI], congestive heart failure [CHF], pneumonia [PN], and Surgical … Clostridium difficile
Infections
Falls
Obstetric Adverse
Events
Pressure
Ulcers/Pressure Injuries
Surgical … Rate of 21 MPSMS adverse events in the MPSMS sample provided by CMS,
including those in the Surgical … National number of selected surgical site infections computed in a special
calculation for CDC. … Data
for the six Patient Safety Indicators and the Surgical Site Infection data from CDC are also wholly
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monahrq.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/lbpinject-topicref.pdf
March 03, 2014 - injections versus epidural nonsteroid injection, nonepidural
injection, no injection, surgery or non-surgical … therapies (e.g., epidural nonsteroid injection, nonepidural
injection, no injection, surgery, or non-surgical … saline epidural, epidural with local anesthetic, nonepidural injection, no
injection, surgery, non-surgical … injection compared to
epidural nonsteroid injection, nonepidural injection, no injection, surgery, or non-surgical … potential modifier of treatment effect, and the Analytic Framework was revised to be clear that
non-surgical
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monahrq.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-rates-2019-updated.pdf
January 01, 2019 - Clostridioides
difficile
Infections
-37%
Falls
-5%
Obstetric
Adverse
Events
-3%
Pressure
Ulcers
Surgical
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4_combo_bestpracticescover.pdf
June 05, 2016 - practices forms exist for the following 14 PSIs:
• PSI 03 Pressure Ulcer Rate
• PSI 05 Retained Surgical … Rate
• PDI 01 Accidental Puncture or Laceration Rate
• PDI 02 Pressure Ulcer Rate
• PDI 03 Retained Surgical … • PSI 04 Death Rate Among Surgical Inpatients With Serious Treatable Conditions: This
PSI calculates
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/Updated-hacreportFInal2017data.pdf
July 01, 2020 - 239,000 8.0
Obstetric Adverse Events 67,000 2.3
Pressure Ulcers/Pressure Injuries 647,000 21.8
Surgical … The other comprised major surgery patients, as described by the Surgical
Care Improvement Project (SCIP … 2015 2016 2017
All Other HACs
(Post-op) Venous
Thromboembolisms
Ventilator-Associated
Pneumonias
Surgical … and Without Instrument
Pressure Ulcer MPSMS Hospital-Acquired Pressure Ulcers/Pressure Injuries
Surgical … National number of selected surgical site infections computed in a special
calculation for CDC.
-
monahrq.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-rates-decline.pdf
June 04, 2018 - Central Line-Associated Bloodstream Infection
Falls
Obstetric
Adverse
Events
Pressure
Ulcers
Surgical
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monahrq.ahrq.gov/research/findings/final-reports/index.html?page=2
September 01, 2018 - and Family Engagement
(3)
Pain Management
(2)
Pressure Ulcers
(2)
Rural Settings
(2)
Surgical … ): Pediatrics Publication Date: August 2017
Improving Patient Safety in Orthopedic Trauma Surgical … Topic(s): Pediatrics Publication Date: November 2016
Effects of Physician Social Networks on Surgical
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monahrq.ahrq.gov/hai/pfp/haccost2017.html
November 01, 2017 - Surgical Site Infections.
Venous Thromboembolism.
Ventilator-Associated Pneumonia. … Central Line-Associated Bloodstream Infections
Falls
Obstetric Adverse Events
Pressure Ulcers
Surgical … Medical errors and HACs affect all age groups, from neonates and mothers during labor and delivery to surgical … Beginning in 2008, CMS identified the HACs (e.g., CAUTI, falls and trauma, surgical site infection) for … Surgical Site Infections (SSI)
Infection that occurs prior to discharge and within 30 days following
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monahrq.ahrq.gov/sites/default/files/publications/files/universalicu.pdf
September 01, 2013 - Total body bathing with ‘Hibiscrub’(chlorhexidine) in surgical patients: a
controlled trial. … Does Universal Decolonization affect the use of skin preps before a surgical procedure?
No. … Can I use CHG cloths over a closed surgical incision? … Be careful to avoid deep surgical wounds. … Are you comfortable applying CHG to closed surgical wounds?
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monahrq.ahrq.gov/cahps/surveys-guidance/hospital/index.html
November 01, 2023 - Hemodialysis
Mental Health Care
Nursing Home
Outpatient and Ambulatory Surgery
Surgical … Survey is a standardized questionnaire for people 18 and older who have been inpatients in medical, surgical