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421. 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.

422. Final Progress Report: Bridging the Gap between EMS and Health Services Research: A Conference for Researchers and Practitioners (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/delia-kutzin-report.pdf
     January 01, 2025 - For example, the Brain Trauma Foundation periodically updates its hyperventilation guideline for the … Impacts of quality reporting in EMS may be driven more by peer pressure and regulation. Dr. … Friedrich von Recklinghausen presented information about the Trauma and EMS Information System (TEMSIS … Other applications involve local epidemiology of injury and demand for EMS services. … Because EMS remains a low-profile issue, researchers feel pressure to “bury” EMS in other projects with

423. 007-Ss-Contact-Precautions-Fg (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/007-ss-contact-precautions-fg.docx
     April 01, 2025 - safety and safe injection practices to minimize the risk of infection transmission and needle stick injury … care equipment between patients – which in the pre-op area and PACU may mean equipment such as a blood pressure … Staff also reported feeling pressure to expedite transport by skipping steps in the contact precautions

424. QDR 2014: Chartbook for Hispanic Health Care, Part 1 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2014chartbooks/hispanichealth/2014nhqdr-hispanichealth-pt1.pdf
     October 01, 2015 - 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,

425. Implement Teamwork and Communication for Perinatal Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/implement/implement-facilitator-guide.pdf
     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, … Example: The nurse says to the doctor, “Doctor, the patient’s blood pressure is dropping; it is 60

426. Usability Testing and the Relation of Clinical Information Systems to Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Rogers.pdf
     January 01, 2003 - Scenario-based testing also identified workplace performance trade-offs related to time and production pressures … ability to identify impact prior to implementation and to suggest redesign before adverse events or injury … Difficulty in design decisions can more easily be created when “typical” work with its time pressure … a series of often unrelated single tasks (e.g., open a program, save a file), without performance pressure … Software used in health care can prevent patient injury or contribute to it, when usability testing

427. Financial and Demographic Influences on Medicare Patient Safety Events (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Bernard.pdf
     January 01, 2004 - Database for Florida from 1996–99 (373,814 discharges at 188 hospitals) to examine whether financial pressure … Shen (2003) examined the effect of financial pressures on patient outcomes and found that financial … pressures adversely affect patient outcomes.7 That study used data from an earlier period (1985–94), … The effect of financial pressure on the quality of care in hospitals. … Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization

428. Transitioning Newborns from NICU to Home: Family Information Packet (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket.pdf
     December 01, 2013 - ■ 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.

429. Transitioning Newborns from NICU to Home: Family Information Packet (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/nicupacket.pdf
     December 01, 2013 - ■ Should have: – Blood pressure checked at every visit. … diarrhea are at risk for zinc defciency and may need supplementation: – Poor growth, diarrhea, impaired wound … ■ BPD, even in the absence of overt brain injury, is a risk factor for neurodevelopmental delay. … – Bivona ■ Cuffed: Indicated to prevent chronic aspiration, or when ventilating with high pressures … – Gastric or esophageal trauma during placement.

430. Diagnostic Failure: A Cognitive and Affective Approach (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Croskerry.pdf
     January 01, 2004 - With disease, injury, or illness, the diagnosis is often obvious and may involve no more than simple … Coercive pressures may drive a particular agenda that is not congruent with good decisionmaking. … For example, team pressures to lower door-to-needle times for thrombolytic therapy in the context of … affective error by changing systemic features: decreased reliance on memory, minimization of time pressure … Minimize time pressures Provide adequate time for quality decisionmaking.

431. Final Progress Report: Evaluating the Impact of Simulated Team Training on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/scott-report.pdf
     January 01, 2024 - Use the ambulatory surgical setting as a model to better understand risks and injuries and to focus … University of Michigan, complications may occur in nearly 13% of cases.4 Preventable healthcare-related injuries … Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization … by the team; and 3) Hypercarbia – the patient becomes hypercarbic with increased peak inspiratory pressures … and implement team training curricula regarding other domains, such as rare event crises in the OR, trauma

432. Making Effective Changes in Antibiotic Decision Making (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/changes-facilitator-guide.pdf
     November 01, 2019 - His heart rate is 100 beats per minute, and his blood pressure is normal at 121 over 75. … This could have prevented the development of acute kidney injury or AKI, and additional laboratory … Using one of the areas of harm, acute kidney injury from unnecessary vancomycin, let’s consider how

433. Final Progress Report: Individualized Performance Feedback on Venous Thromboembolism Prevention Practice (pdf file)
     www.ahrq.gov/sites/default/files/2025-06/haut-report.pdf
     January 01, 2025 - handwashing, VTE prevention, medication prescribing, diagnostic imaging, medication reconciliation, pressure … injury prevention, antibiotic use, discharge summary, and laboratory testing. … Receive feedback Want feedback Patient nutrition Medication reconciliation Handwashing Pressure … injury prevention VTE Prevention Antibiotic use Medication prescribing Discharge summary

434. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-pediatric-safety-refs.html
     August 01, 2023 - Identification of children at very low risk of clinically-important brain injuries after head trauma: … Physicians' Risk Tolerance and Head Computed Tomography Use for Pediatric Patients With Minor Head Injury … Cluster Randomized Trial Reducing Missed Elevated Blood Pressure in Pediatric Primary Care: Project RedDE … Disparities in the evaluation and diagnosis of abuse among infants with traumatic brain injury. … The use of telemedicine in the care of the pediatric trauma patient. Semin Pediatr Surg .

435. Screening for Family and Intimate Partner Violence: Systematic Evidence Review (pdf file)
     www.ahrq.gov/downloads/pub/prevent/pdfser/famviolser.pdf
     March 01, 2004 - Inflicted injury versus accidental injury. [Review] [87 refs]. … Validation of a Trauma Questionnaire in veteran women. … Analytic Framework and Key Questions *Including physical trauma (fractures, dislocations, brain injury … If answer is yes, code “1” for no injury, “2” for possible injury, and “3” for injury. … 6 = Use of weapon, wound from weapon 4.

436. Urine Culturing Stewardship in the ICU Setting Facilitator Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urine-culturing-notes.docx
     April 01, 2022 - Her temperature is 100.8 degrees Fahrenheit, heart rate 130, respiratory rate 22, and blood pressure … mistakenly considered an unavoidable “cost of doing business” instead of understood as avoidable, tragic injury

437. Intravenous Infusion Safety Initiative: Collaboration, Evidence-Based Best Practices, and “Smart” Technology Help Avert High-Risk Adverse Drug Events and Improve Patient Outcomes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Maddox_38.pdf
     March 26, 2008 - leading cause of patient harm is medication errors, which account for almost 20 percent of medical injuries … .1 Twenty-eight percent of medication-related injuries (adverse drug events, ADEs) are considered preventable … Anesthesia Patient Safety Foundation (APSF) notes a significant, underappreciated risk of serious injury … with other medication errors, IV infusion programming errors have a greater likelihood of causing injury … programmed, appropriate doses of opiates can suppress respiration and decrease heart rate and blood pressure

438. Final Progress Report: A National Report of Nursing Home Quality Measures and Information Technology (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/alexander-report.pdf
     January 01, 2024 - daily living has increased; 2) who have moderate to severe pain; 3) who are at high risk and have pressure … sores; 4) who are at low risk and who have pressure sores; 5) who are physically restrained; 6) who … the percentage of residents 1) with delirium; 2) who have moderate to severe pain; 3) and who have pressure … Symptoms 14168 797 5.6 5.1 Who Were Physically Restrained 14203 798 0.9 0.7 One or More Falls with Major Injury … Physically Restrained -0.02 -0.02 0.01 0.01 0.01 0.01 0.01 0.00 -0.02 0.00 One or More Falls with Major Injury

439. Final Progress Report: Proactive Risk Assessment of Primary Care of the Elderly (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/karsh-report.pdf
     January 01, 2024 - Results: Major hazards identified included time pressure, lack of coordination between physician and … hazards. 18,19,33 3 It is well recognized in safety engineering that the heart of safety lies not in injuries … A hazard is anything that increases the probability of errors or of patient/ employee injury and is … -Sutures removed too soon after minor surgical procedure and wound dehiscence, which requires 6 weeks … Patient gets dizzy after first dose, falls, but no injury and stops med.

440. Documentation of Heart Rate During Fluid Resuscitation for Children With Severe Sepsis or Septic Shock (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-232-fullreport.pdf
     June 01, 2018 - (hypotension), as children often maintain normal blood pressure until the advanced stages of shock … A limited window of opportunity exists for treating underlying injury once shock is present. … , central venous pressure, urine output, metabolic status, and peripheral perfusion (Rooney, Nadel, … Because children often maintain their blood pressure until they are severely ill, systemic hypotension … For severe sepsis, one abstractor indicated that there was a low systolic blood pressure despite the