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341. 162-Example-Completed-Learning-Defects-Tool (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/162-example-completed-learning-defects-tool.docx
     October 01, 2024 - Current: He was found unconscious at home after a suspected syncopal episode with injury to his chest … First vitals included a blood pressure of 75/40, temperature of 38.5°C, heart rate of 110 beats per minute … His blood pressure continued to remain low, and it was decided to place a central line and begin a vasopressor

342. 52-Regional-Analgesia-Arthroplasty-Facilitator (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/52-regional-analgesia-arthroplasty-facilitator.docx
     June 01, 2023 - Neuraxial blocks can lead to decreased blood pressure and profound motor nerve block, which may not be … of regional analgesia in the setting of anticoagulation to avoid the potential risk of neurological injury

343. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention - Facilitator Training: Overview of On-Time (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxoverview-ig.pdf
     June 02, 2025 - of On-Time This version of On-Time introduction is for training Facilitators who have not had pressure …  It is more difficult for staff to identify which residents are at risk for a fall or pressure … electronic reports with input from relevant staff (e.g., nursing assistants, director of nursing [DON], wound … weekly basis and encourage multidisciplinary input (e.g., certified nursing assistants [CNAs], DON, wound … when On-Time pressure ulcer prevention reports were integrated into day-to-day workflow

344. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/manage-resident-RTI-slides.pptx
     June 01, 2021 - Case 1: Diagnostic Evaluation Temp 99.2° Fahrenheit Heart rate 98 beats per minute Blood pressure … antibiotic therapy Clinical instability Unable to maintain oxygen saturation Hypotension (systolic blood pressure … Pneumonia Versus Pneumonitis8 21 Aspiration Pneumonitis Aspiration Pneumonia Pathophysiology Acute lung injury

345. Improving Patient Safety in Long-Term Care Facilities, Module 1 (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/ltcmodule1.pdf
     June 01, 2012 - She has high blood pressure, diabetes, and arthritis. She is also being treated for depression. … pressure ulcer (bed sore) if not responded to promptly. … it is an observed and assisted transition to the floor or an unwitnessed event that results in an injury … Vital Signs Vital signs include temperature, respiratory rate, blood pressure, and pulse rate. … Residents are safest – protected from harm or injury – when everyone expects to openly report anything

346. 018-Revision-Summary-Contact-Precautions (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/018-revision-summary-contact-precautions.docx
     October 01, 2024 - contact, changes in care that contribute to delays and non-infectious adverse events (e.g., falls, pressure … injuries), increased symptoms of depression and anxiety, and decreased patient satisfaction.16 · Adverse

347. Network of Patient Safety Databases Chartbook, 2023 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2023-rev.pdf
     January 01, 2023 - An example of additional detail from the Fall module would be the type of injury sustained in a fall … Pressure Ulcers result in harm to the patient by their very nature. … This is unexpected, as pressure ulcers result in harm to the patient by their very nature. … unstageable • A lesion that, on admission, was a suspected Deep Tissue Injury • A pressure ulcer … Pressure Ulcers result in harm to the patient by their very nature.

348. 2018 National Healthcare Quality and Disparities Report: Appendix A (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2018qdr-appa6.pdf
     January 01, 2018 - - injury to neonate per 1,000 selected live births -7.28 -1.12 HCUP 2016 Reclosure of postoperative … abdominal wound dehiscence per 1,000 abdominopelvic- surgery admissions of length 2 or more days, adults … or shoulder belts when riding in a car 15.84 2.24 MEPS 2016 Reclosure of postoperative abdominal wound … - injury to neonate per 1,000 selected live births 17.13 2.25 HCUP 2016 Sepsis diagnoses per 1,000 … - injury to neonate per 1,000 selected live births 18.63 2.19 HCUP 2016 Appendix A: List of

349. Ratio of Magnetic Resonance Imaging Scans to Computed Tomography Scans for the Evaluation of Children with Atraumatic Headache (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-196-fullreport.pdf
     January 01, 2020 - children with secondary headaches accompanied by neurological signs or symptoms of increased intracranial pressure … in blood pressure; and/or irregular heart rhythms (Society for Pediatric Anesthesia, 2014). … headache in the absence of documented neurologic signs or symptoms that suggest increased intracranial pressure … , new neurologic deficits, or signs and symptoms of increased intracranial pressure may require timely … Incidental findings in children with blunt head trauma evaluated with cranial CT scans.

350. Hypertension Screening for Children Who Are Overweight or Obese: Report (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-0232-fullreport.pdf
     February 01, 2020 - percentile (2) documentation of diastolic blood pressure percentile, (3) classification of blood pressure … Markers of vascular injury can be detected in very young children, demonstrating that the path to cardiovascular … , systolic blood pressure value, diastolic blood pressure value, and both height and weight (necessary … blood pressure, diastolic blood pressure, height, and weight) was 100 percent, with a Kappa statistic … Systolic or diastolic blood pressure values. 30 7.

351. The National Action Alliance to Advance Patient Safety Summer Webinar Series - PowerPoint Presentation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/public-action-alliance-slides-040323_LOCKED.pdf
     May 25, 2023 - factors focus areas • Workplace Change Collaborative – National Framework on Burnout and Moral Injury … “By and large, the U.S. does not account for medical care injuries and deaths in our vital statistics … Where it should say 'medical care harm/injuries', it's blank. … as surge … our new normal *Healthcare Acquired Infections, Early Elective Deliveries, Falls with Injury … , Healthcare Acquired Pressure Injuries, NTSV C-Section patients to get to WHO Goal, Sepsis Mortality

352. Hospital Survey on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.pdf
     June 02, 2025 - • “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

353. Hospital Survey on Patient Safety (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.doc
     June 02, 2025 - · “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

354. Hospital Survey on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/hospscanform.pdf
     June 02, 2025 - • “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

355. Using an Anonymous Web-Based Incident Reporting Tool to Embed the Principles of a High-Reliability Organization (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Conlon_50.pdf
     May 06, 2008 - Data are gathered about the type of event, the location of the event, contributing factors, injuries … • Ensure there are no reprisals for reporting of errors and injuries, both actual occurrences and … of particular importance because all team members must be prepared to move quickly to prevent such injury … There has been a 36 percent reduction in the pressure ulcer rate since July 2006. … The number of patient falls with injury per 1,000 inpatient days is one of the core clinical indicators

356. 2018 National Healthcare Quality and Disparities Report: Appendix A (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2018qdr-appa5.pdf
     January 01, 2018 - per 1,000 vaginal deliveries without instrument assistance -54.51 -35.20 HCUP 2016 Obstetric trauma … - injury to neonate per 1,000 selected live births 8.00 1.46 HCUP 2016 Accidental puncture or laceration … 18 and over or obstetric admissions 75.00 4.24 HCUP 2016 Reclosure of postoperative abdominal wound … People Relative Difference Z Score Data Source Data Year Reclosure of postoperative abdominal wound … - injury to neonate per 1,000 selected live births 3.3 0.50 HCUP 2016 Adults who had a doctor’s office

357. Lessons in Safety Climate and Safety Practices from a California Hospital Consortium (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Singer.pdf
     April 01, 2003 - This heightened interest has increased pressure on hospitals to reduce medical errors. … Increased regulatory and payer pressures have encouraged hospital leaders to undertake efforts to improve … For example, one consortium participant from a large multihospital network created an injury graph that … Based on this analysis, she categorized injuries by hospital. … The visual image helped motivate the organization to set system goals for reducing patient injuries.

358. Implement Teamwork and Communication for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/implement-fac-guide.html
     July 01, 2023 - Slide 6: Root Causes of Maternal and Perinatal Deaths and Injuries 2004-2012 Say: Human factors … communication breakdowns are identified as the primary root cause of maternal and perinatal deaths and injuries … Other root causes for maternal and perinatal deaths and injuries are— Assessment. … Example: The nurse says to the doctor, "Doctor, the patient's blood pressure is dropping; it is 60/

359. Overuse of Computed Tomography Scans for the Evaluation of Children with a First Generalized Afebrile, Atraumatic Seizure: Report (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0198-fullreport.pdf
     November 01, 2019 - These complications include compromised airway, hypoxia leading to central nervous system (CNS) injury … • Neurologic signs of increased intracranial pressure. … sedation, moderate and deep sedation carry a greater risk of airway compromise, hypoxia resulting in CNS injury … These risks include dental trauma; airway edema (swelling of the windpipe); vocal cord spasm or injury … ; regurgitation of stomach contents with subsequent aspiration (inhalation) pneumonia; injury

360. Ed-Catheter-Insertions-Transcript (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/ed-catheter-insertions-transcript.doc
     September 10, 2013 - So because of his immobility, he developed a pressure ulcer on his sacrum and the physician decided to … Now we know the elderly are very vulnerable to infection and other injury in the hospital. … Possibly, the patient needs immobilization for trauma or surgery, patient is incontinent with open wounds … ; protocolized care for trauma; incontinence without open sacral or perineal wounds; pre-operative placement … On the next slide, we’ll – one case study is trauma.