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121. Tool 2: How To Begin the Re-engineered Discharge Implementation at Your Hospital | Agency for Healthcare Research and Quality
     preventiveservices.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool2.html
     March 01, 2013 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

122. Findings From the AHRQ Transforming Primary Care Grant Initiative: A Synthesis Report (pdf file)
     preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/tpc/tpc-synthesis-report.pdf
     July 22, 2015 - post-implementation period.33 The trend applied to emergency care use overall and to asthma and unintentional injury … Specifically, the percent of PCMH patients hospitalized per month (overall and for asthma and unintentional injury … Donahue, MD, MPH Diabetes • HbA1c <9% • LDL cholesterol <100 mg/dL • Blood pressure <130/80 … ≤130/80 mm Hg • LDL cholesterol ≤100 mg/dL Cardiovascular disease: • Blood pressure ≤130/80 … Gabbay, MD, PhD Diabetes • HbA1c <7% • Blood pressure <130/80 mm Hg • LDL cholesterol <100

123. 4. How do you implement the fall prevention program in your organization? | Agency for Healthcare Research and Quality
     preventiveservices.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/implementation.html
     January 01, 2013 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … Or as implementation advances and the new practices become the norm, peer pressure may spur resisters … Hospitals will not be reimbursed by Medicare for hospital-acquired falls with trauma.

124. Advancing Patient Safety | Agency for Healthcare Research and Quality
     preventiveservices.ahrq.gov/patient-safety/reports/advancing/index.html
     July 01, 2022 - private-public partnerships to: (1) identify the causes of preventable health care errors and patient injury … By using hospital administrative data, PSIs can identify pressure ulcers, postoperative pulmonary emboli … Education in 2003 and that the long shifts medical interns worked led to 61 percent more needlestick injuries

125. Module 2: How To Manage Change (doc file)
     preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module2/module2_fall-prevention.docx
     August 24, 2017 - applied to other quality improvement efforts in a hospital, such as preventing: Hospital-acquired pressure … injuries.

126. Pediatric Diagnostic Safety: State of the Science and Future Directions (pdf file)
     preventiveservices.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-pediatric-safety.pdf
     September 01, 2023 - status, extremes of age, delirium, or poor information exchange between health systems; ■ Time pressures … Identification of children at very low risk of clinically- important brain injuries after head trauma … Cluster Randomized Trial Reducing Missed Elevated Blood Pressure in Pediatric Primary Care: Project … Disparities in the evaluation and diagnosis of abuse among infants with traumatic brain injury. … The use of telemedicine in the care of the pediatric trauma patient. Semin Pediatr Surg.

127. 2022 National Healthcare Quality and Disparities Report Appendixes (pdf file)
     preventiveservices.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2022qdr-appendix-combined.pdf
     October 25, 2022 - HCUP 2019 Home health care patients whose management of oral medications improved OASIS 2020 Birth trauma … pressure ulcer MDS 2019 Low-risk, long-stay nursing home residents with a catheter inserted and left … MDS 2019 Short-stay nursing home patients with pressure ulcers that are new or worsened MDS 2018 … HCUP 2019 Home health care patients whose management of oral medications improved OASIS 2020 Birth trauma … MDS 2019 Short-stay nursing home patients with pressure ulcers that are new or worsened MDS 2018

128. Webinar Transcript - The National Quality Strategy and the Public Sector: Federal Agency Alignment to the Six Priorities | Agency for Healthcare Research and Quality
     preventiveservices.ahrq.gov/workingforquality/events/webinar-federal-agency-alignment-to-the-six-priorities.html
     November 01, 2016 - We work to prevent the leading cause of illness, injury, disability, and death. … We've displayed performance on the ABCs, which are appropriate aspirin use, blood pressure control, control … tobacco and got preventive care, we still have to address modifiable risk factors, including blood pressure … their profit according to the extent to which they're able to assist their members in controlling blood pressure

129. Fall Prevention Toolkit (doc file)
     preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module2/module2_tools.docx
     November 16, 2011 - Monthly falls analysis by: location and time of fall shift and day of week type of injury … consequences of falls High-risk medications, sleep hygiene measures for management of anxiety Low blood pressure

130. Return on Investment Tool (pdf file)
     preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/f1_combo_returnoninvestment.pdf
     January 01, 2013 - For example, improvement actions might reduce hospital-associated infections, rates of pressure ulcers … Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization

131. Current State of Diagnostic Safety: Implications for Research, Practice, and Policy - Issue Brief (pdf file)
     preventiveservices.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-current-state.pdf
     January 01, 2024 - that patients with diagnosis-related claims were 2.33 times more likely to die than to have a minor injury … and have been associated with increased medical errors and stress, anxiety, and burnout.113,114 Time pressure … diagnostic safety found the need to prioritize research on system factors, such as workload, time pressure … Preventable diagnostic errors in fatal cervical spine injuries: a nationwide register-based study from … Adv Wound Care (New Rochelle). 2013 Dec;2(10):588-592. http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3865615

132. AHRQ Safety Program for Perinatal Care: Experiences from the Frontline (pdf file)
     preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_lowvision.pdf
     May 01, 2017 - Root cause analyses of adverse events and near-misses (events that did not produce patient injury) … The AHRQ Patient Safety Indicator 18 (Obstetric Trauma–Vaginal Delivery with Instrument) decreased … in-house neonatal death, uterine rupture during labor, unplanned maternal admission to ICU, birth trauma … processes at the point of care to include specific maternal parameters, including blood loss, blood pressure … They established a standard process for blood pressure measurement upon admission and during labor

133. AHRQ Safety Program for Perinatal Care: Experiences from the Frontline (pdf file)
     preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_fullcolor.pdf
     May 01, 2017 - Root cause analyses of adverse events and near-misses (events that did not produce patient injury) … The AHRQ Patient Safety Indicator 18 (Obstetric Trauma–Vaginal Delivery with Instrument) decreased … in-house neonatal death, uterine rupture during labor, unplanned maternal admission to ICU, birth trauma … processes at the point of care to include specific maternal parameters, including blood loss, blood pressure … They established a standard process for blood pressure measurement upon admission and during labor

134. Diagnostic error in mental health: a review (pdf file)
     preventiveservices.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-mental-health-bmjqs.pdf
     April 15, 2024 - Despite the importance of effective data gathering and synthesis, time pressures, competing priorities … J Trauma Dissociation 2017;18:233–47. 31 Sheehan DV, Lecrubier Y, Sheehan KH, et al. … procedures: are diagnosticians influenced by the narrative fallacy when assessing the psychological injuries … of trauma victims Psychol Inj Law 2016;9:265–71. 54 Jenkins MM, Youngstrom EA.

135. Making Informed Consent an Informed Choice: Training for Health Care Professionals Audio Script | Agency for Healthcare Research and Quality
     preventiveservices.ahrq.gov/health-literacy/professional-training/informed-choice/audio-script.html
     September 01, 2020 - The final challenge is the time pressure we all face. … Some goals may be long-term, such as reducing the risk of future injury or illness, or living as long … Mom: I don't think I could forgive myself if he wound up dying of meningitis because we didn't finish … Non-invasive routine care, such as taking blood pressure, is usually covered by the blanket consent form

136. Making Informed Consent an Informed Choice: (pdf file)
     preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/audio-script-healthcare-professionals-training.pdf
     January 18, 2017 - The final challenge is the time pressure we all face. … Some goals may be long-term, such as reducing the risk of future injury or illness, or living as long … Mom: I don’t think I could forgive myself if he wound up dying of meningitis because we didn’t finish … Non-invasive routine care, such as taking blood pressure, is usually covered by the blanket consent

137. Hospital Survey on Patient Safety Culture: User's Guide (pdf file)
     preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/userguide/hospitalusersguide.pdf
     July 01, 2018 -  “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events … Whenever pressure builds up, my supervisor/manager wants us to work faster, even if it means taking shortcuts … Whenever pressure builds up, my supervisor/manager wants us to work faster, even if it means taking