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361. Healthcare Safety Competencies Affinity Group Environmental Scan (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/engineering-safety-practice/healthcare-safety-competency-environmental-scan.pdf
     March 27, 2025 - including central line-associated bloodstream infections, ventilator-associated events, hospital-acquired pressure … injuries, patient falls, and catheter-associated urinary tract infections during the COVID-19 pandemic … Bureau of Labor Statistics, in 2018, healthcare workers accounted for 73% of all nonfatal workplace injuries … Safety Science- Adjacent • Workload Management • Burnout • Worker Safety • Fatigue • Moral Injury … The Human Experience • Burnout • Co-Design • Fatigue • Improving Access to Care • Moral Injury

362. 2019 National Healthcare Quality and Disparities Report Quality Trends (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr-core-measures-quality.pdf
     January 01, 2019 - 51.9% in 2013 67.7% in 2017 -9.5 0.006 Surgical Safety Home health care patients whose surgical wound … single measure that was not changing over time examines long-stay nursing home patients who experience injuries … Ulcers Short-stay nursing home patients with new or worsening pressure ulcers (MDS) 0.7% in 2013 … Ulcers High-risk, long-stay nursing home patients with pressure ulcer (MDS) 5.3% in 2013 4.8% in … 2017 -2.1 0.018 Falls Long-stay nursing home patients experiencing one or more falls with major injury

363. Care Coordination Quality Measure for Primary Care (CCQM-PC) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/coordination/ccqmpc/ccqm-pc-survey-instructions.pdf
     July 01, 2016 - most of your usual health care needs and who you normally see when you need care for a new illness or injury … being able to walk a flight of stairs without losing your breath, or target rates—for example, a blood pressure … In the last 12 months, if you had an illness or injury, how often did your primary care provider or … 1 Never 2 Sometimes 3 Usually 4 Always 5 I did not have an illness or injury in the last … High blood pressure or hypertension? Congestive heart failure? Coronary artery disease?

364. AHRQ Views: Celebrating the 40th Anniversary of the U.S. Preventive Services Task Force | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/920.html
     July 01, 2024 - 36 states from AHRQ’s Healthcare Cost and Utilization Project focusing on adverse outcomes such as pressure … Epidemiology and clinical outcomes of community-acquired acute kidney injury in the emergency department

365. Transitioning Newborns from NICU to Home: Family Information Packet, Appendix B (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb.pdf
     June 02, 2025 - ■ Should have: – Blood pressure checked at every visit. … are at risk for zinc deficiency and may need supplementation: – Poor growth, diarrhea, impaired wound … – Bivona ■ 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.

366. Final Progress Report: Developing Best Practices for Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/baker-report.pdf
     January 01, 2024 - delivery of hospital care.14 15 16 17 18 19 By some estimates, as many as a half million preventable injuries … preventable deaths may occur each year, at a cost estimated to exceed $30 billion per year.20 Most of these injuries … evidence on the effectiveness and cost of comprehensive patient safety programs for reducing avoidable injuries … Production pressure in the work environment: California anesthesiologists' attitudes and experiences … Production pressure in the work environment: California anesthesiologists' attitudes and experiences

367. Final Progress Report: The Value of Hospital-Related Patient-Safety Interventions to Key Stakeholders (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/nuckols-report.pdf
     January 01, 2024 - Only half of basic care processes are provided as recommended, and injuries due to medical errors (preventable … electronic health records with computerized provider order entry (CPOE), which may reduce patient injuries … Conclusions: In hospital-related settings, implementing CPOE is associated with >50% decline in patient injuries … Cost Implications of Improving Blood Pressure Management among U.S. Adults.

368. Do Transient Working Conditions Trigger Medical Errors? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Grayson.pdf
     January 01, 2003 - .6, 10–12 Injuries to workers result from a causal chain of events involving both latent and immediate … Indeed, many risk factors for injury that have been studied in case-crossover studies of injury are … circumstances may be the result of other working conditions, such as a hectic work environment, time pressures … Case-crossover studies of occupational trauma: methodological caveats. … Injury Prevention 2001;7:Supplement 38–42.

369. Fundamentals of Medicare Patient Safety Surveillance: Intent, Relevance, and Transparency (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Hunt.pdf
     July 01, 2004 - This urgency is, in part, precipitated by the confluence of market pressures to demonstrate value in … DVT/PE* Hospital acquired UTI** Ventilator associated pneumonia** Adverse drug events ** Pressure … care postoperative stays has shifted the diagnostic location for a large percentage of postoperative wound … reliable proxies for this event in the administrative claims, our ability to identify postoperative wound … A study of medical injury and medical malpractice: an overview.

370. Guide-Infection-Prevention (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/guides/guide-infection-prevention.pdf
     March 01, 2017 - ▪ Infections cause pain, injury, disability, and sometimes even death, and can be very expensive … ▪ Cover all cuts and wounds with a dressing. … resident, if needed, that the law requires the use of safety lancets and needles to prevent needle stick injuries … ▪ Make sure that wounds are covered. ▪ Contain any urine, stool, or wound drainage. … ▪ An LTC facility must have negative pressure rooms and a respiratory fit-test program in order to

371. Practice and Quality Improvement | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/reports/2024-annual-report/recent-grants-improvement.html
     May 01, 2024 - Appendix D: Grant Summaries P1: Does A New Care Model Improve Care for Patients with Acute Kidney Injury … would improve the use of a hypertension focused clinical decision support to effectively improve blood pressure … support in rural primary care practices to provide evidence-based clinical care recommendations for blood pressure … program that supports patients discharged from the hospital to home after an episode of acute kidney injury … health improvement project in 60 primary care clinics throughout Alabama to improve rates of blood pressure

372. Organizational Behavior Management in Health Care: Applications for Large-Scale Improvements in Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Cunningham_11.pdf
     January 29, 2008 - percent).5 In terms of overall numbers, preventable technical complications of surgery (10,891) and wound … Postoperative wound dehiscence 15. Transfusion reaction Treatment 5. … Birth trauma and obstetric trauma (3 types related to delivery methods) Preventive 10. … as “response generalization.”36 This line of OBM research informed an intervention to decrease injuries … individual access to computers; d) adding clinical decision support; e) instigating relevant peer pressure

373. Paul Tedrick (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/building-team-transcript.doc
     April 08, 2014 - The fourth indication is the healing of open wounds that are close to the groin area. … , such as a motor vehicle accident where they have an injury to the spinal cord. … Assisting healing with a perineal or sacral wound in certain patients. … or multiple traumatic injuries, such as multiple fractures, and you worry that, again, movement will … Wound care nurses, we talked about, the pressure associated with the Foley catheter is helping.

374. Building a Team and Process to Reduce CAUTI Risk (April 8, 2015) | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/building-teamwork-transcript.html
     December 01, 2017 - The fourth indication is the healing of open wounds that are close to the groin area. … , such as a motor vehicle accident where they have an injury to the spinal cord. … Assisting healing with a perineal or sacral wound in certain patients. … or multiple traumatic injuries, such as multiple fractures, and you worry that, again, movement will … Wound care nurses, we talked about, the pressure associated with the Foley catheter is helping.

375. Presentation: Program Overview
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/vaesurveillance-slides.pptx
     January 01, 2017 - Best Practices for VAE Reduction RECOMMENDATION INTERVENTION Basic practice Use noninvasive positive pressure … probiotics Ultrathin polyurethane endotracheal tube cuffs Automated control of endotracheal tube cuff pressure … complications through fluid conservation Protect against atelectasis by managing sedation Combat acute lung injury

376. Understanding the CMS Patient Safety Structural Measure Requirements for Hospitals (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/understanding-cms-patient-safety-measure-hospitals-webcast.pdf
     July 08, 2025 - improvement activities on safety events (such as: medication errors, surgical/procedural harm, falls, pressure … injuries, diagnostic errors, and healthcare-associated infections).” 31 Domain 3 Statement C:

377. Regulation of Health Policy: Patient Safety and the States (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Weinberg.pdf
     March 01, 2004 - In this research, we examined State legislative responses to pressure from constituents and policymakers … or disability or the immediate danger of serious injury or disability”); and Class C (an adverse event … Nevada defines a sentinel event as “an unexpected occurrence” involving death or serious injury or the … According to JCAHO, the classification of an AE that was avoided or did not result in injury is drawn … In recent years, State legislatures have deflected pressure to regulate health care away from the Federal

378. Effect of Recent Refresher Training on in Situ Simulated Pediatric Tracheal Intubation Psychomotor Skill Performance (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Nishisaki_44.pdf
     April 19, 2008 - • Hypotension: systolic blood pressure <70 mmHg.9 • Intubation failure: o No intubation success … Nadkarni); the Center for Injury Research and Prevention (Dr. … Committee on Trauma. Advanced trauma life support student manual. 7th ed. … The infant has no evidence of increased intracranial pressure. … Each subject was reminded to “pay attention to” the potential cervical spine injury, but a person was

379. Final Progress Report: Implementing Reduced Work Hours for All House Staff To Improve Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/landrigan2-report.pdf
     January 01, 2024 - begin their work day 8-10 hours after awakening (86), leaving them with more accumulated homeostatic pressure … (i.e., injuries from needle sticks and scalpel laceration), and ‘fall-asleep’ incidents. … extended-duration shifts compared to non-extended-duration shifts. (99) In addition, the odds of a needlestick injury … A computer alert system to prevent injury from adverse drug events. JAMA 1998;280(1317):1320. … Extended work duration and the risk of self-reported percutaneous injuries in interns.

380. Final Progress Report: Incident Reporting Practices in Nursing Homes (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/castle-report.pdf
     January 01, 2025 - states, however; for example, abuse incidents are taken very seriously, but falls, other incidents, and pressure … events or medication errors; resident altercations or other types of abuse; and non-fall related injuries … Compared to 38.5% surveyor visits for burns and 22.7% for pressure ulcers, the numbers are fairly low … The relationship between physical restraint removal and falls and injuries among nursing home residents … ., dispensing, administration, adverse drug event) 27 17.3 6.3 69.3 7.1 24 12.5 4.2 66.7 16.7 Pressure