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4861. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33822/psn-pdf
      January 01, 2017 - we had similar circumstances in plants in Russia, China, Hungary, or any place in the world, as long … hospitals with a central line had a central line infection, and that was considered normal and inevitable … Rick Shannon, who was then at the Allegheny General Hospital in charge of three intensive care units … The University of Pittsburgh Medical Center has about 22 hospitals. … Children's Hospital.

4862. Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation | PSNet
      psnet.ahrq.gov/web-mm/bandemia-harbinger-stercoral-colitis-and-impending-perforation
      November 25, 2020 - Three days later, the patient was admitted to a second hospital with perforated bowel and sepsis. … Among 167 and 205 patients who presented to two community hospitals with normal total leukocyte counts … bands; adjusted OR, 6.2, 95% CI, 3.2-11.8 for high bands), including gram-negative bacteremia, and in-hospital … investigation in this setting. … September 29, 2021 WebM&M Cases EMS Perils from Hospital

4863. AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/slides.html
      December 01, 2014 - Falls Prevention. Prevention of Avoidable Hospitalizations. … Large decline in pressure ulcer incidence rate seen in Pressure Ulcer Prevention Program Evaluation. … Identify residents with recent changes in risks. Profile risks for each resident in report. … Review calculation details in report. Check the accuracy of the data in the medical record. … Engage in discussions about care changes.

4864. STATISTICAL BRIEF #478: Trends in Prescribed Outpatient Opioid Use and Expenses in the U.S. Civilian Noninstitutionalized Population, 2002-2012
      meps.ahrq.gov/data_files/publications/st478/stat478.shtml
      August 01, 2015 - STATISTICAL BRIEF #478: Trends in Prescribed Outpatient Opioid Use and Expenses in the U.S. … Only prescriptions purchased or obtained in an outpatient setting are included in these estimates. … Prescription medicines administered in an inpatient setting or in a clinic or physician's office are … MPC data are generally used for hospital-based events (e.g., inpatient stays, emergency room visits, … Trends in Prescribed Outpatient Opioid Use and Expenses in the U.S.

4865. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49649/psn-pdf
      March 01, 2012 - Part of this commentary is based on my experience as a physician in Vietnam in the 1960s and 34 years … In a systematic review of 7000 refugees, PTSD was found in 9% and major depression in 5%, with considerable … comorbidity.(4) In a study in Australia, long-term Vietnamese refugees had a prevalence rate of PTSD … There are several important changes clinics and hospitals can make to address the needs of refugee patients … In: Okparu SO, ed. Clinical Methods in Transcultural Psychiatry.

4866. PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-slides.pptx
      November 01, 2016 - Development: Falls Prevention Prevention of Avoidable Hospitalizations November 2016 On-Time Overview … Review calculation details in report. Check the accuracy of the data in the medical record. … Engage in discussions about care changes. … The team typically pilots a report in one unit initially. … The team pilots additional reports in one unit.

4867. PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/factraining_slides.pptx
      December 01, 2014 - reports and implementation materials Hands-on practice using the reports and implementation materials in … What are obstacles to staff obtaining the information needed to identify residents who need changes in … Being Developed for Four Adverse Events Four Reports Pressure Ulcer Prevention Pressure Ulcer Healing Falls … How will communication occur with other disciplines to confirm changes in care? … What is the Facilitator’s role in helping with the Self-Assessment?

4868. Transcript: How To Empower Nurses To Effectively Implement a Nurse-Driven Protocol for Removing Urinary Catheters, Including How To Obtain Buy-In From Physicians (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/empowering-nurses-transcript.pdf
      April 01, 2022 - Joseph Mercy Hospital Ann Arbor, MI [Opening music] Kate Schmidgall: This audio interview is a production … In critical care especially, the indication in critical care that is typically used as “why I have this … catheter in” is to monitor intake and output in the critically ill patient. … And so, we have education sheets on, you have this in, these are the risks of having it in. … [End of recording] [Recorded in 2018, reviewed in 2022] AHRQ Pub.

4869. Module 1- Component Kit (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/overview/component-kit.docx
      May 01, 2017 - Many improvement projects fail to result in sustained gains. … In the United States, organizations included Intermountain Healthcare, Virginia Mason Hospital & Medical … Ambulatory surgery centers (ASCs) generally have such standard work firmly in place in the form of policies … kits in this series. … AHRQ has made available tools that will help you apply the ideas in this module and the others in this

4870. Presentation: Program Overview
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/measuredesc-dailyearlymobility-slides.pptx
      January 01, 2017 - Let’s Begin… Fill out for all beds Track by bed, not by patient Include Bed number Was the patient in … patient was intubated If the date is not available*, enter admission date (either to the unit or to the hospital … Sitting in bed/exercises in bed 3. Sitting at edge of bed 4. Standing 5. … Marching in place 7. Walking 8. Unknown 1. Tipping C, Bailey M, Bellomo R, et al. … (14) Hypotension or hypertension (17, 18) Cardiac arrest (20) Fall with or without staff assisting in

4871. Conceptual Paradigms of Diagnostic Quality, Safety, and Excellence | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology5.html
      April 01, 2025 - It is also applied in clinical quality measures widely used in public reporting and value-based programs … However, in this context, it has been difficult to evaluate harm (or change in outcome) independent of … In contrast to general problems in patient safety that tend to focus on iatrogenic harm or dangerous … The diagnostic process can also result in indirect  harm, such as when attempts to rule in or rule out … medical conditions result in excessive testing or when insignificant incidental findings result in psychological

4872. 09-0071-Ef 1 (pdf file)
      digital.ahrq.gov/sites/default/files/docs/page/09-0071-EF_1.pdf
      June 01, 2009 - RHIO stakeholders may include hospitals, primary care physicians, specialty physicians, laboratories … § Malpractice insurance (for physicians): indemnifies a physician for negligence (conduct that falls … In some cases, the RHIO may have key partners that are government entities—such as public hospitals—that … In the case of the MSeHA, some of the public hospitals in Tennessee fall under the Tennessee Claims … those who are more financially viable such as health insurers and large hospitals, have voiced this

4873. Pediatric Medical Complexity Algorithm (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-141-fullreport.pdf
      July 01, 2017 - algorithm using Washington and Minnesota Medicaid data and have found very similar percentages of children falling … Children's hospitals wanting to identify complex children for programmatic purposes (Vanderbilt, University … In work done with the Children's Hospital Association, we have also demonstrated an increasing proportion … of complex children cared for at children's hospitals in recent years. … Provider Level Hospital: Can compare hospitals Intended use: Is measure intended to support meaningful

4874. Final Progress Report: Exploratory Study Using Queuing Theory To Improve Nurse Staffing Effectiveness (pdf file)
      www.ahrq.gov/sites/default/files/2024-10/stone-report.pdf
      January 01, 2024 - of data throughout both hospital and unit-level nurse staffing research vary. … For example, in a hospital emergency room, the triage system is an example of a priority queue discipline … hospitals. 5 Methods A 42-bed orthopedic surgical unit was our test site. … This assumption is valid for many hospitals and is also consistent with other nurse staffing methodologies … Though the information technology software that is currently used by hospitals provides real-time support

4875. Transitioning to the SOPS™ Hospital Survey Version 2.0: What’s Different and What To Expect, Part II: Appendixes (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hsops2-pt2_transition_apx.pdf
      September 01, 2019 - this hospital, how long have you worked in your current unit/work area? … This composite measure was 4 percentage points higher on HSOPS 2.0 for the 2019 pilot hospitals. … other hospitals are likely to have difference scores that vary from this average—some hospitals will … have smaller difference scores and other hospitals will have larger difference scores. … SOPS Hospital Survey Simultaneous Administration Results Comparison Tool—for hospitals that conduct

4876. Trends in Hospital Inpatient Stays in the United States, 2005-2014 (pdf file)
      hcup-us.ahrq.gov/reports/statbriefs/sb225-Inpatient-US-Stays-Trends.pdf
      December 01, 2016 - a decrease in hospital stays. … Nonspecific chest pain and coronary atherosclerosis decreased by more than 60 percent from 2005 to 2014, falling … hospitals for patients aged 0–17, 18–44, and 45–64 years in 2014. … Beginning in 2012, long- term acute care hospitals are also excluded. … hospitals).

4877. Module 5: How To Measure Pressure Injury Rates and Prevention Practices | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/guide5.html
      October 01, 2017 - This tracking of key indicators is critical to improving prevention practices in this hospital. … NDNQI is used by many hospitals, but there are various options to measure pressure injuries. … this hospital? … The hospital launched a Pressure Injury Prevention Program using the AHRQ Toolkit in April 2015. … for pressure injury prevention in this hospital.

4878. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60268/psn-pdf
      April 29, 2020 - Almost a decade ago, Arkansas Children's Hospital reported seven adverse events in 57 transfers (12.3% … emergencies Intra-hospital/in-hospital ECMO transport team Critical ECMO transport team members would … programs, that professional may not always be available in-hospital or, as in the current case, may … Check that device supply/supplies are connected to the most secure source/s, i.e. in hospital plugs for … In-Hospital Neurologic Complications in Adult Patients Undergoing Venoarterial Extracorporeal Membrane

4879. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/850361/psn-pdf
      June 14, 2023 - After the patient was readmitted with endocarditis, he had a complicated hospital course resulting in … in this case involved the transition from hospital to skilled nursing facility. … Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. … The incidence and nature of in-hospital adverse events: a systematic review. … Adverse Events in Hospitals: Case Study of Incidence Among Medicare Beneficiaries in Two Selected Counties

4880. Late Anemia Following Rh Disease in a Newborn | PSNet
      psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn
      June 17, 2010 - clinicians now recognized that the infant had active Rh hemolytic disease, and he was admitted to the hospital … , which causes benign, mild jaundice in adults and can contribute to elevated bilirubin levels in newborns … In addition, although it is common in patient safety discussions to focus on errors of omission ( 9 ) … a community hospital network. … Pregnancy June 1, 2010 Finding blunders in thyroid testing: experience in