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341. 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.

342. 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.

343. 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/

344. Communication Assessment Guide: Appendix 2 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/ap2.html
     August 01, 2022 - During her procedure, her heart rate, blood pressure, and oxygen level were monitored. … During a part of the procedure, we became aware that her heart rate, blood pressure, and oxygen level … First off, right now Mary is stable; her heart rate, blood pressure, and oxygen level are all in normal … We also don't know right now if she has suffered any injury from what happened, but we will check her

345. 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

346. Appendix B. Clinical Materials to Share With Primary Care Providers (continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/resource/nicu/packet/apb2.html
     December 01, 2013 - BPD, even in the absence of overt brain injury, is a risk factor for neurodevelopmental delay. … Vent frequently to prevent gas pressure from compromising the seal. … Cuffed: Indicated to prevent chronic aspiration, or when ventilating with high pressures. … Set suction pressure between 80-100 mmHg. … Gastric or esophageal trauma during placement.

347. Appendix B. Clinical Materials to Share With Primary Care Providers (continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/resource/nicu/packet/apb2.html
     December 01, 2013 - BPD, even in the absence of overt brain injury, is a risk factor for neurodevelopmental delay. … Vent frequently to prevent gas pressure from compromising the seal. … Cuffed: Indicated to prevent chronic aspiration, or when ventilating with high pressures. … Set suction pressure between 80-100 mmHg. … Gastric or esophageal trauma during placement.

348. Module 3. Falls Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mgdod3.html
     October 01, 2014 - In addition, they should be able to manage injuries that result from falls. … Risk factors are identified, and ways to prevent injury are discussed. … Develop participants' knowledge and skills in preventing falls and fall-related injuries. … He has moderate dementia, and his blood pressure falls when he stands up too fast, making him dizzy. … Paul comes to visit his father after work; he is aware that his father fell yesterday, without injury

349. Emergency Department and Catheter Insertion | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/ed-catheter-insertions-transcript.html
     December 01, 2017 - 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.

350. 2018 National Healthcare Quality and Disparities Report: Appendix A (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2018qdr-appa4.pdf
     January 01, 2018 - - injury to neonate per 1,000 selected live births 4.5 0.67 HCUP 2016 Adults age 40 and over with … - injury to neonate per 1,000 selected live births 7.4 1.33 HCUP 2016 Adults with chronic joint symptoms … health only per 100,000 population 46.1 5.39 HCUP_NEDS 2016 Reclosure of postoperative abdominal wound … - injury to neonate per 1,000 selected live births 6.7 1.24 HCUP 2016 Children 41-80 lb for whom a … sores or irritation in the calendar year 36.3 2.34 MEPS 2016 Reclosure of postoperative abdominal wound

351. 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

352. Acute Care Learning From Defects
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/changes-slides.pptx
     November 01, 2019 - associated with biliary duct obstruction from a gallstone Temperature of 101° F, pulse of 100, and blood pressure … Acute kidney injury and unnecessary lab tests and imaging could have been avoided 3 Piperacillin/tazobactam … Care Learning From Antibiotic-Associated Adverse Events Adverse event: Patient develops acute kidney injury

353. 2022 National Healthcare Quality and Disparities Report Executive Summary (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2022qdr-final-es.pdf
     October 01, 2022 - injury deaths), followed by accidental falls and motor vehicle accidents (each of which accounted for … approximately 20% of unintentional injuries) … an important cause of death that disproportionately affects younger populations, was unintentional injury … • Among the top 10 causes of YPLL, rates of unintentional injury, heart disease, liver disease, and … eclampsia/preeclampsia rate, which measures a complication of pregnancy characterized by high blood pressure

354. Making Health Care Safer II, Executive Summary (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-based-reports/services/quality/patientsftyupdate/ptsafetysum.pdf
     March 01, 2013 - “common;” examples include falls, venous thromboembolism (VTE), potential adverse drug events, or pressure … The scope must also consider the severity of each event; for instance, most falls do not result in injury … patient safety target, such as adverse drug events, or general clinical topics, such as preventing pressure … High (hypoglycemia) Low-to- moderate NA Interventions to prevent contrast-induced acute kidney injury … Common/ Moderate High Moderate (bleeding) Low Little/Moderate Preventing patient death or serious injury

355. Final Progress Report: Health Journalism 2011, national conference on healthcare journalism (pdf file)
     www.ahrq.gov/sites/default/files/2024-05/bruzzese3-report.pdf
     January 01, 2024 - Soldiers with traumatic brain injuries. Athletes with concussions. … care o From pee wee to pro: Head injuries in sports o Can the FDA ensure food safety? … Journalism Graduate Program • How nanotechnology may revolutionize the detection of traumatic brain injury … interim deputy director, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury … "Sim Man" and "Harvey" reproduced physiological signs, such as blood pressure and heart and breathing

356. Communication: Obstetric Hemorrhage - PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_3_communication.pptx
     July 01, 2023 - interruption to a doctor who is with a patient's family members. 2 Maternal and Perinatal Deaths and Injuries … 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 (i.e., the adequacy, … Her blood pressures have remained normotensive, and she has had good reflexes throughout the shift. … Her blood pressures have remained normotensive, and she has had good reflexes throughout the shift.” 

357. Appendix III (continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apiiid.html
     June 01, 2010 - A few are related to the health and welfare of clients, such as injuries and medication errors. … HCBS MS Domains: Unmet Need Populations: Individuals with disabilities, adults with acquired brain injuries … information concerning the number of incidents (abuse and neglect; restraints, crimes against, serious injuries … required data via NCI form titled "NCI Protocol for Reporting Incidents: Abuse and Neglect, Serious Injuries … additional measures under development relate to influenza vaccinations for people with disabilities and pressure

358. Toolkit for Reducing CAUTI in Hospital Units: Implementation Guide (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/implementation-guide_0.pdf
     September 01, 2015 - ulcers or similarly severe wounds that cannot be kept clear of urinary incontinence despite wound care … require strict prolonged immobilization following specific types of trauma or surgery. … Examples include instability in the thoracic or lumbar spine, multiple traumatic injuries such as pelvic … Intermittent catheterization is most often used in patients with neurogenic bladder or spinal cord injury … despite wound care and other urinary management strategies, if ISC is adequate to manage the type of

359. Toolkit for Reducing CAUTI in Hospital Units: Implementation Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide.pdf
     September 01, 2015 - ulcers or similarly severe wounds that cannot be kept clear of urinary incontinence despite wound care … require strict prolonged immobilization following specific types of trauma or surgery. … Examples include instability in the thoracic or lumbar spine, multiple traumatic injuries such as pelvic … Intermittent catheterization is most often used in patients with neurogenic bladder or spinal cord injury … despite wound care and other urinary management strategies, if ISC is adequate to manage the type of

360. Part 1: Overviews of the Report and the Hispanic Population | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/part1.html
     March 01, 2020 - For example, only half of people with high blood pressure have it controlled. … Leading causes of morbidity and mortality include heart disease, cancer, unintentional injuries, stroke