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41. Achievements in Primary Care | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/evidencenow/projects/heart-health/about/stories/achievements.html
    March 01, 2021 - Health Center Holly Clinic (Holy, CO)   Helping primary care practices use evidence to improve blood pressure … selected Million Hearts® Hypertension Control Champions have worked with their patients to achieve blood pressure

42. C1 Prioritization Worksheet (xls file)
    teamstepps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.xlsx
    July 01, 2016 - Value-based purchasing • Sentinel event • Publicly reported • Public perception • Marketing • Competitive pressure … Patient Safety PSI 03 Pressure Ulcer   PSI 06 Iatrogenic Pneumothorax PSI 07 Central Venous Catheter-Related … Neonatal Blood Stream Infection Rate Pediatric PDI 01 Accidental Puncture or Laceration Rate PDI 02 Pressure

43. Final Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
    teamstepps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014FinalHACreport4Web-13Dec2016.pdf
    December 01, 2016 - About 40 percent of the overall reduction is from adverse drug events, about 28 percent from pressure … Tract Infections Central Line-Associated Bloodstream Infections Falls Obstetric Adverse Events Pressure … Most of the deaths averted occurred as a result of reductions in the rates of pressure ulcers and adverse … 2014) OB Trauma in Vaginal Delivery With (PSI 18) and Without Instrument (PSI 19) 74,000 2.3 Pressure … Ulcers MPSMS (2014) Hospital-Acquired Pressure Ulcers 1,010,000 30.9 Surgical Site Infections

44. AHRQ Quality Indicators Prioritization Worksheet Example (pdf file)
    teamstepps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.pdf
    June 29, 2016 - purchasing • Sentinel event • Publicly reported • Public perception • Marketing • Competitive pressure … PSI 03 Pressure Ulcer 1.2 1.3 7 $109,870 $ 769,087 N 6 7 7 Y Y Y Y Y PSI 06 Iatrogenic … purchasing • Sentinel event • Publicly reported • Public perception • Marketing • Competitive pressure … purchasing • Sentinel event • Publicly reported • Public perception • Marketing • Competitive pressure … Y N PDI 01 Accidental Puncture 0.3 0.6 1 $41,204 $ 41,204 N 9 9 9 Y Y Y Y Y PDI 02 Pressure

45. Clabsitoolsap5 (doc file)
    teamstepps.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/clabsitools/clabsitoolsap5.doc
    December 11, 2012 - lumen (to avoid air embolism and ensure intravascular placement) Transduce central venous pressure … or estimate central venous pressure by fluid column (to avoid arterial placement) After the

46. Reducing Diagnostic Errors in Primary Care Pediatrics Toolkit | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/patient-safety/settings/ambulatory/diagnostic-safety/toolkit.html
    November 01, 2018 - systematic approach to reduce diagnostic errors among children in three important areas: Elevated blood pressure … Increased Provider Recognition of Elevated Blood Pressure in Children. 

47. EvidenceNOW: North Carolina Cooperative | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/evidencenow/projects/heart-health/about/cooperatives/north-carolina.html
    March 01, 2021 - patients adopt the ABCS of cardiovascular disease prevention: Aspirin in high-risk individuals, Blood pressure … physical activity targets. 3 Only half of patients treated for hypertension currently have their blood pressure … Blood pressure control among patients has increased close to an absolute of 5 percentage points. … Recent trends in the prevalence of high blood pressure and its treatment and control, 1999-2008.

48. Saving Lives and Saving Money: Hospital-Acquired Conditions Update | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/hai/pfp/2014-final.html
    January 01, 2018 - About 40 percent of the overall reduction is from adverse drug events, about 28 percent from pressure … Most of the deaths averted occurred as a result of reductions in the rates of pressure ulcers and adverse … 2014) OB Trauma in Vaginal Delivery With (PSI 18) and Without Instrument (PSI 19) 74,000 2.3 Pressure … Ulcers MPSMS (2014) Hospital-Acquired Pressure Ulcers 1,010,000 30.9 Surgical Site Infections … been wrongly based on the full cost of a hospital stay that included a fall or a hospital-acquired pressure

49. Introduction to Communication and Optimal Resolution (CANDOR): Video | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/patient-safety/settings/hospital/candor/videos/introduction.html
    August 01, 2022 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

50. Appropriate Disclosure to a Patient: Video | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/patient-safety/settings/hospital/candor/videos/app-disclosure.html
    August 01, 2022 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

51. Inappropriate Disclosure to a Patient: Video | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/patient-safety/settings/hospital/candor/videos/inapp-disclosure.html
    August 01, 2022 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

52. Accountability—Peer to Peer Coaching: Video | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/patient-safety/settings/hospital/candor/videos/accountability.html
    August 01, 2022 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

53. Planning for Meetings with Family: Video | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/patient-safety/settings/hospital/candor/videos/meeting.html
    August 01, 2022 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

54. EvidenceNow Executive Summary - North Carolina Cooperative (pdf file)
    teamstepps.ahrq.gov/sites/default/files/wysiwyg/evidencenow/cooperatives/evidencenow-executive-summary-nc.pdf
    November 01, 2017 - patients adopt the ABCS of cardiovascular disease prevention: Aspirin in high-risk individuals, Blood pressure … physical activity targets.3 Only half of patients treated for hypertension currently have their blood pressure … • Blood pressure control among patients has increased close to an absolute of 5 percentage points … Recent trends in the prevalence of high blood pressure and its treatment and control, 1999-2008.

55. Evidence for Advancing Heart Health | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/evidencenow/projects/heart-health/evidence/index.html
    March 01, 2021 - Health Evidence for Advancing Heart Health Aspirin Use Evidence and Resources Blood Pressure … adopt the ABCS of cardiovascular disease prevention: Aspirin use by high-risk individuals Blood pressure

56. AHRQ Tools To Reduce Hospital-Acquired Conditions | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/hai/hac/tools.html
    March 01, 2024 - Non-ICU Patients With Devices Obstetrical adverse events: Toolkit for Improving Perinatal Safety Pressure … ulcers: Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care Surgical

57. National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts To Make Health Care Safer | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/hai/pfp/2015-interim.html
    December 01, 2016 - About 42 percent of this reduction is from adverse drug events, about 23 percent from pressure ulcers … Ulcers MPSMS (2015) Hospital-Acquired Pressure Ulcers 1,190,000 36.3 Surgical Site Infections … 17.4% 1,040,500 NA NA $9,141,150,000 35,647 * Additional costs per HAC for Falls and Pressure … been wrongly based on the full cost of a hospital stay that included a fall or a hospital-acquired pressure … [7] The AHRQ-developed pressure ulcer toolkit and falls toolkit are online.

58. Methods To Estimate the Baseline 2010 PFP National Hospital-Acquired Condition Rate | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/hai/pfp/methods.html
    December 01, 2017 - Adverse Events PSI OB Trauma in Vaginal Delivery With (PSI 18) and Without Instrument (PSI 19) Pressure … Ulcers MPSMS Hospital-Acquired Pressure Ulcers Surgical Site Infections NHSN SSIs combined … Tract Infections 18.80 25.58 0.73 Falls In-Hospital Patient Falls 12.25 14.56 0.84 Pressure … Ulcers Hospital-Acquired Pressure Ulcers 53.03 62.45 0.85 VAP Ventilator-Associated Pneumonia … Ulcer MPSMS Hospital-Acquired Pressure Ulcers 1,317,211 32,750,000 40.220 Surgical Site

59. NPSD Dashboards | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/npsd/data/dashboard/index.html
    October 01, 2023 - Pressure Ulcer Dashboard Details the documentation of increased risk for pressure ulcer following a … risk assessment; and the timing of the first risk assessment for reported pressure ulcers or sDTIs.

60. Overview: Getting Patients Off the Ventilator Faster: Facilitator Guide | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/hai/tools/mvp/modules/vae/overview-off-ventilator-fac-guide.html
    February 01, 2017 - weight for patients without ARDS and 4-6cc/kg predicted body weight for patients with ARDS, plateau pressure … of less than or equal to 30 cm H 2 O, and the use of positive end-expiratory pressure instead of zero … end-expiratory pressure—can prevent further pulmonary complications. … To do so, use positive end-expiratory pressure greater than or equal to 5cm H 2 0, not zero end-expiratory … pressure (ZEEP), maintain plateau pressure at less than or equal to 30cm H 2 0, and use tidal volume