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401. Identifying, Understanding, and Communicating Medical Device Use Errors: Observations from an FDA Pilot Program (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flack.pdf
     January 01, 2005 - 519, mandates that all manufacturers of medical devices must report device-related deaths, serious injuries … facilities” must report medical device related deaths to FDA and to the manufacturer and report serious injuries … of medical devices so it could become more proactive in addressing device issues before a death or injury … the various types and sizes of facilities that are obligated to make reports of deaths and serious injuries … systems are really at the root of the problem, and c) clinicians report they are just too busy with the pressures

402. CAHPS End of Life Care Survey (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/end-of-life/end-of-life-care-survey-english.pdf
     December 03, 2024 - Hypertension or high blood pressure? d. Cancer? e. … Please mark one or more. 1 Accident or injury 2 The flu (Influenza), pneumonia, or COVID?

403. Appendix VII: Public Comments Submitted Between March 7 and March 21, 2008 (continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apviia.html
     June 01, 2010 - of State Directors of Developmental Disabilities Services, the National Associations of State Brain Injury … agencies, units on aging, agencies serving individuals with physical disabilities, traumatic brain injury … Medicaid-eligible individuals who are frail and elderly, have intellectual and developmental disabilities, head injuries … of State Directors of Developmental Disabilities Services, the National Associations of State Brain Injury … future and the "Never Events," I did not see any use of the never events, including: Stage 3 or 4 pressure

404. Factors that Impact Perinatal Care Experience and Outcomes: Slide Presentation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/webinars/perinatal-care-experience-slides.pdf
     March 06, 2025 - Function, quality of life, satisfaction • Harms (eg, mistreatment, disrespectful care, birth related injury … Days 43 Days to One Year Maternal Deaths by Time Period and Cause Mental Health Condition High Blood Pressure … ng a P C P vi si t w ith sp ec ifi c pr im ar y ca re s er vi ce s, % Blood pressure

405. Envisioning Patient Safety in the Year 2025: Eight Perspectives (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Henriksen_104.pdf
     January 01, 2025 - Patients are fully compensated for all costs of injuries; we provide emotional support for patients … Forum), and requires health care organizations to compensate patients for costs of treatment-related injuries … management and facility model will be paired with a regionally centralized system of critical and trauma … support consumer groups to assure authenticity, to accelerate progress in patient safety through public pressure … episodes—necessarily resulting from the variegated and heterogeneous nature of human physiology, of illness and injury

406. Technical Appendix | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tap.html
     December 01, 2012 - in a 1915(c) for aged and disabled people; aged people only; disabled people only; people with brain injuries … , 758.31, 758.33, 758.39, 758.7, 759.5, 759.81-759.83, or 759.89), developmental delay-severe brain injury … who are under age 65 and are not classified as I/DD or SMI (includes, for example, traumatic brain injury … Prevalence of high blood pressure, State's . … "Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure

407. Appendix B. Clinical Materials to Share With Primary Care Providers | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/resource/nicu/packet/apb.html
     December 01, 2013 - supplementation, mechanical ventilation, air leaks, pulmonary edema, PDA ligation, infection causing lung injury … Blood pressure: Not higher in infants with nephrocalcinosis, but overall higher in preterm infants … Should have: Blood pressure checked at every visit. … diarrhea are at risk for zinc deficiency and may need supplementation: Poor growth, diarrhea, impaired wound

408. Appendix B. Clinical Materials to Share With Primary Care Providers | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/resource/nicu/packet/apb.html
     December 01, 2013 - supplementation, mechanical ventilation, air leaks, pulmonary edema, PDA ligation, infection causing lung injury … Blood pressure: Not higher in infants with nephrocalcinosis, but overall higher in preterm infants … Should have: Blood pressure checked at every visit. … diarrhea are at risk for zinc deficiency and may need supplementation: Poor growth, diarrhea, impaired wound

409. AHRQ Safety Program for MRSA Prevention
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/049-dec-implementation-slides.pptx
     October 01, 2024 - and Dressings8 Recommended for superficial wounds Friable skin/rashes Superficial burns Pressure injuries … Recent nasal surgery or trauma: Discuss with your hospital’s ENT surgeons to establish guidelines for … CHG is approved as a wound cleanser. … Encourage wound care nurses to provide support to staff who are uncomfortable. … SHIELD: Eliminating Multidrug-Resistant Organisms; FAQ: Wound Care.

410. Comparison Tables for Making Healthcare Safer Reports | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/making-healthcare-safer/comparison.html
     June 01, 2025 - (Not reviewed) (Not reviewed) (Not reviewed) Interventions To Prevent Contrast-Induced Acute Kidney Injury … Summary of Evidence (all patients) (Not reviewed) (Not reviewed) Preventing Patient Death or Serious Injury … Summary of Evidence Summary of Evidence (all patients) (Not reviewed) (Not reviewed) Prevention of Pressure

411. Error Producing Conditions in the Intensive Care Unit (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Drews_15.pdf
     February 26, 2008 - Time pressure in error detection. 3. Low signal-to-noise ratio. 4. … percent), the surgical ICU (8 percent), the neurological critical care unit (8 percent), and the burn-trauma … 38 ICU workplace (%) Medical 68 Thoracic 12 Surgical 8 Neurological critical care 8 Burn-trauma … Given the problems outlined above, it is no surprise to find that under time pressure, the operation … Preventing ventilator-related death and injuries.

412. Final Progress Report: Weekend Effects and the July Phenomenon in Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/weissman-report.pdf
     January 01, 2024 - The PSIs identify “birth trauma” in low-risk births with documentation of hypoxic injury, nerve injuries … , and several other types of injuries. … It is known that anesthesiologists have been effective at identifying factors, such as production pressure … anesthetic poisoning AND active drug dependence, active nondependent abuse of drugs, or self-inflicted injury … (N) Inc: liveborn infants Exc: infants w/subdural or cerebral hemorrhage, pre-term infants, injury

413. Introducing the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture: Webcast Transcript (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/ascwebinar/ascwebcast0715_transcript.pdf
     September 01, 2015 - our overall efforts in patient safety, and as part of the National Action Plan for health-associated injuries … Smith, Slide 23 And the area with the most room for improvement was Staffing, Work Pressure and Pace … Smith, Slide 25 The two bottom-performing items were from Staff Training and the Staffing, Work Pressure … And you can see that for Staffing, Work Pressure and Pace it was a 94 percent positive compared to a … Brown, Slide 44 Our second area of focus was Staffing, Work Pressure and Pace, and our result was 55

414. 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/cati-script.pdf
     July 01, 2016 - 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 … professionals in this office ask whether you had enough services to help you take care of this illness or injury … NEEDED] 1 Never 2 Sometimes 3 Usually 4 Always, or 5 I did not have an illness or injury … High blood pressure or hypertension? 66e. Congestive heart failure? 66f.

415. Mod5-Comm-Assessment (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-comm-assessment.pdf
     April 01, 2016 - Eventually, they are able to re-establish a normal heart rate, blood pressure, and adequate blood oxygen … 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

416. Final Progress Report: Improving Medication Safety Across Clinical Settings (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/bates-report.pdf
     January 01, 2024 - brought it to the forefront of public attention.1 The IOM report estimated that more than a million injuries … that many patients annually are injured as a result of medications.3;4 Furthermore, many of these injuries … developing systems that prevent and buffer errors, we gathered information about the types and causes of injuries … The most common injuries resulting from ADEs were cardiovascular, especially hypotension, defined as … a systolic blood pressure less than 90 mm Hg (40%), and metabolic derangements, such as severe hypoglycemia

417. Diagnostic Safety Centers of Excellence Grants Awarded in FY 2022 | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/research/grants-2022.html
     July 01, 2025 - Use of ChatGPT for Urinary Symptom Management Among People With Spinal Cord Injury or Disease: Qualitative … evidence, diagnostic practices, and outcomes for the problems of unintentional weight loss, high blood pressure … clinical problems above, based on analysis of EHR data; existing evidence, including from a home blood pressure

418. Safe Practices for Better Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kizer1.pdf
     April 01, 2004 - Not surprisingly, health care errors and consequent adverse events are a leading cause of death and injury … Introduction Health care errors and consequent adverse events are a leading cause of death and injury … Evaluate each patient upon admission, and regularly thereafter, for his or her risk of developing pressure … contrast media-induced renal failure, and use a clinically appropriate method for reducing risk of renal injury … Use of specialized hospital flooring to reduce injury from patient falls. 3.

419. Improving the Safety and Quality of Health Care: The Impact of the National Academy of Medicine on Research and Collaboration (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/dzau-summit2016.pdf
     September 28, 2016 - private-public partnerships to: • Identify the causes of preventable health care errors and patient injury … approximately $19.8 billion in health care costs were saved from 2010 to 2014 Adverse Drug Events Pressure … • Unsafe care causes 43 million injuries a year and the loss of 23 million disability- adjusted

420. Overuse of Imaging for the Evaluation of Children with Simple Febrile Seizure: Final Report (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-192-fullreport.pdf
     November 01, 2019 - These complications include compromised airway, hypoxia leading to central nervous system injury, and … • Signs or symptoms of increased intracranial pressure (Table 10 [=IMG11]; see Supporting Documents … • Signs or symptoms of increased intracranial pressure. • Abnormal neurologic exam. … These risks include dental trauma; airway edema (swelling of the windpipe); vocal cord spasm or injury … Incidental findings in children with blunt head trauma evaluated with cranial CT scans.