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381. 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.

382. 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

383. 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.

384. 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.

385. Fundamentals of Medicare Patient Safety Surveillance: Intent, Relevance, and Transparency (pdf file)
     www.ahrq.gov/downloads/pub/advances/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.

386. 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.

387. 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

388. 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

389. 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

390. Overview of Patient Safety Learning Laboratory (PSLL) Projects | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/index.html
     August 01, 2025 - as pressure injury) from exposure to intense and/or prolonged pressure, moisture, friction, and shear … ’s achievements include the creation of a digital bedside display that shows patients’ catheter and wound … injuries (formerly called ‘pressure ulcers’). … injury) and rhythmic motion (for detection of seizure). … caregivers in the design of health information technology (IT) tools to prevent patient falls and related injuries

391. 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.

392. 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.

393. 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

394. 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

395. 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

396. 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.

397. 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

398. Final Progress Report: Demonstration Project To Refine, Automate and Test a Novel Emergency Department Trigger Tool (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/griffey-report.pdf
     January 01, 2025 - preventable.6-9 Numerous factors, such as increasing acuity, limited data for decision making, time pressures … We queried home medications, chief complaint, triage data such as acuity and trauma leveling, keywords … BiPAP – bilevel positive airway pressure; CPAP – continuous positive airway pressure; D50 – 50% Dextrose … (11%), and pressure ulcers (12.3%). … hypoxia and hypotension, delirium/ confusion, various bleeding events, surgical complications and injuries

399. Improving Patient Safety in Long-Term Care Facilities: Training Modules (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/ltcinstructor.pdf
     June 01, 2012 - safety, create a more resident-centered environment, and reduce the number of falls and fall-related injuries … In addition, they should be able to manage injuries that result from falls. … Risk factors are identified, and ways to prevent injury are discussed. … Paul comes to visit his father after work; he is aware that his father fell yesterday, without injury … use to reduce the number of falls. › Nursing staff must have the knowledge and skills to prevent injury

400. Implement-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/implement/implement-facilitator-guide.docx
     May 01, 2017 - 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, Leadership, Information … Example: The nurse says to the doctor, “Doctor, the patient’s blood pressure is dropping; it is 60/40