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441. Primary Care Practice Facilitation Curriculum Module 31: Facilitating Panel Management (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-31-facilitating-panel-management.pdf
     September 01, 2015 - acute care centers—services rendered to patients needing urgent medical attention (e.g., infection, injuries … The registry can also identify patients not in control of HbA1c, LDL, or blood pressure, patients who … Other information may need to be input by someone in the clinic, for example, blood pressure, weight … The Panel Manager may also have the job to enter data into the registry (like blood pressures) and to … Which of these patients would you call to schedule a group blood pressure clinic appointment? b.

442. Unique Challenges in Approaching Diagnostic Safety in Older Adults | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-older-adults2.html
     September 01, 2024 - presented to his physical therapist 23 days after falling off a ladder, resulting in a mild traumatic brain injury … Lamjoun, et al. (2023) 39 Normal pressure hydrocephalus and mania symptoms: case report A 54-year-old … e.g., registered nurses, clinical pharmacists, social workers, nutritionists) and face institutional pressure

443. Final Progress Report: Connected Emergency Care (CEC) Patient Safety Learning Lab (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/hinson-levin-report.pdf
     January 01, 2025 - compounded in the emergency department (ED) by a hazardous decision-making environment fraught with time pressure … data-driven studies of infectious disease diagnostics performance,9,10 in-depth study of acute kidney injury … Renal outcomes following intravenous contrast administration in patients with acute kidney injury: a … Optimal Acute Kidney Injury Algorithm for Detecting Acute Kidney Injury at Emergency Department Presentation … Epidemiology and Clinical Outcomes of Community-Acquired Acute Kidney Injury in the Emergency Department

444. Advances in Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/advances/index.html
     July 01, 2022 - Reige Surveillance Detection of Inpatient Health Care Associated Injuries: Comparing Two ICD-9-CM … Song, Tracey Pritchett Developing a Veterans Health Administration (VHA) Serious Injury Surveillance … Jaser, Nancy Safer, Paul Davern Medical Injury Identification Using Hospital Discharge Data (   PDF … Nozick Clinical Informatics and Its Usefulness for Assessing Risk and Preventing Falls and Pressure

445. Final Progress Report: Shared Decision Making in Surgery To Improve Patient Safety and Reduce Liability (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/domino-report.pdf
     January 01, 2024 - Physicians already felt pressure to reduce or limit time with patients to meet scheduling demands and … outpatient treatment, unplanned admission or readmission, or emergency room visit), or new physical injury … In contrast, the nature of most errors was equipment injuries (23%), diagnostic delays or failures ( … Medical errors leading to complaints included medication errors (n=5), equipment injuries (n=3), diagnosis … and dollar amounts Patient complaints were more likely than errors to result in some new physical injury

446. Emergency Nurses Association content and transcript (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/guides/ena-slides.pdf
     September 01, 2015 - Need for resources • What teams need to be activated (specialists, code team, trauma team, brain injury … While a catheter may prove useful in advanced-stage pressure ulcers, there are many other products that … Additionally, the presence of a catheter can cause pressure and may damage fragile tissue. … • The patient who requires immobilization for trauma or surgery  Inquire about the length of the … • The patient who is incontinent with open sacral or perineal wounds  Consult with the wound care

447. Emergency Nurses Association content and transcript (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/ena-slides.pdf
     September 01, 2015 - Need for resources • What teams need to be activated (specialists, code team, trauma team, brain injury … While a catheter may prove useful in advanced-stage pressure ulcers, there are many other products that … Additionally, the presence of a catheter can cause pressure and may damage fragile tissue. … • The patient who requires immobilization for trauma or surgery  Inquire about the length of the … • The patient who is incontinent with open sacral or perineal wounds  Consult with the wound care

448. Strategies to Better Engineer Safety into Healthcare Delivery (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/engineering-safety-practice/safety-engineering-strategies.pdf
     March 06, 2025 - that make it more difficult for people to make errors in care delivery or experience a work-related injury … designed to reduce the transmission of healthcare-associated infections and the risk of occupational injury … Healthcare Settings includes strategies to identify risks and hazards and prevent/control work-related injury … Healthcare-Associated Infections Program (contains multiple resources and toolkits)  • Preventing Pressure

449. Labor and Delivery Unit Safety: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/ldu-safety-slides.html
     July 01, 2023 - Intrauterine pressure catheter or fetal scalp electrode placement. Manual rotation. … Effects of shoulder dystocia training on the incidence of brachial plexus injury. … Shoulder dystocia and injuries: prevention and management.

450. Safety Climate on Hospital Units: A New Measure (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Blegen.pdf
     January 01, 2004 - Studies have identified a number of factors that affect the rate of worker injury. … authority.13 There is research examining the climate of safety in health care as it impacts worker injuries … reactions of supervisors, the training in use of technology, performance appraisals that include safety, pressures … perceptions of work group members regarding the protection of patients from medication errors and injuries … teamwork, risk perception, process auditing, A Hospital Safety Climate Measure 441 production pressures

451. Global Assessment of Pediatric Patient Safety (GAPPS) Trigger Tool (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-fullreport.pdf
     April 01, 2018 - This measure calculates the rate of adverse events (patient harm)—defined as unintended physical injury … Black and Hispanic newborns are at higher risk of birth trauma (Miller, et al., 2003). … Although AEs most often result in transient harms, some lead to permanent injury and death. … : "Naloxone administration," “Health care- associated infections: positive C. difficile test,” and "Pressure … Internal pressures, such as a punitive culture that leads to underreporting of medical errors, may influence

452. Improving Patient Safety in Ambulatory Surgery Centers: A Resource List for Users of the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture. (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc-resource_list.pdf
     March 01, 2016 - Staffing, Work Pressure, and Pace ................................ 4 Composite 4. … Effective Crisis Management Living a Culture of Patient Safety Policy and Brochure Medically Induced Trauma … Staffing, Work Pressure, and Pace 1. … portfolio aims to identify risks and hazards that lead to medical errors and find ways to prevent patient injury … Staffing, Work Pressure, and Pace Composite 4. Teamwork Composite 5. Staff Training Composite 6.

453. Timely Antibiotics for Children With Severe Sepsis or Septic Shock (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0230-fullreport.pdf
     April 02, 2018 - Unlike adults, the diagnosis of septic shock in children does not require the presence of low blood pressure … (hypotension), as children often maintain normal blood pressure until the advanced stages of shock … A limited window of opportunity exists for therapy of the underlying injury once shock is present. … 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

454. Timely Fluid Bolus for Children With Severe Sepsis or Septic Shock (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0231-fullreport.pdf
     May 01, 2018 - Unlike adults, the diagnosis of septic shock in children does not require the presence of low blood pressure … (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. … 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

455. 7.  Appendix C: Additional Tables by Topic Area | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/reports/2024-annual-report/appendix-c.html
     May 01, 2024 - Appendix D: Grant Summaries P1: Does A New Care Model Improve Care for Patients with Acute Kidney Injury … program that supports patients discharged from the hospital to home after an episode of acute kidney injury … Prioritizing Quality Improvement for the Treatment of Psychiatric Disturbances Following Traumatic Brain Injury … support in rural primary care practices to provide evidence-based clinical care recommendations for blood pressure … practice facilitation would improve the use of a hypertension-focused CDS to effectively improve blood pressure

456. Final Progress Report: Improved Patient Safety with Information Technology (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/overhage-report.pdf
     January 01, 2024 - The report estimated more than a million injuries and nearly 100,000 deaths attributable to medical … medication opportunities (not on an indicated med); (4) failed intermediate outcomes – e.g., high blood pressures … with CHF who are euvolemic (compensated) and on a low dose of an ACE inhibitor with systolic blood pressure … of 110, diastolic blood pressure of 80, and a heart rate of 76, adding a beta blocker is the next most

457. Final Progress Report: Making Acute Care More Patient Centered, Patient Safety Learning Laboratory (PSLL) (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/bates3-report.pdf
     January 01, 2024 - concordance by patients and care team members, and the incidence of patient falls and fall-related injuries … The effect of the intervention on patient falls (dichotomized as fall/no fall) and falls with injury … (dichotomized as falls with injury/no injury) was analyzed using logistic regression estimated via … Scope Inpatient adverse events (AEs) are patient injuries due to medical management that prolong hospitalization … Bowel Regimen, Venous Thromboembolism (VTE) Prophylaxis, Opioid Management, Antibiotic Management, Pressure

458. A Patient Safety Program & Research Evaluation of U.S. Navy Pharmacy Refill Clinics (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Reige.pdf
     March 01, 2004 - an acute skeletal muscle relaxant medication for nearly a year; it was originally prescribed for injuries … Elderly people are at a higher risk for falls resulting in serious injury, and when a person is dizzy … When an elderly patient falls, serious injury may occur. … Part of the medication renewal process involves checking the patient’s blood pressure or performing

459. AHRQ Transforming Primary Care Grants | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/research-transform-primary-care/transform/tpcbib/index.html
     May 01, 2015 - Hemoglobin A1c and blood pressure values in patients with diabetes were not significantly different between … The number of hospitalizations for unintentional injury and asthma also decreased after implementation … PMID: 23690385 The authors compared emergency care usage for any reason, asthma, and unintentional injury … As a comparison, emergency care use for unintentional injury had been increasing before and during implementation … Among patients with hypertension, frequent in-person visits were associated with better blood pressure

460. AHRQ Transforming Primary Care Grants Bibliography | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/reports/grants-transform/bibliography/index.html
     February 01, 2017 - Hemoglobin A1c and blood pressure values in patients with diabetes were not significantly different between … The number of hospitalizations for unintentional injury and asthma also decreased after implementation … PMID: 23690385 The authors compared emergency care usage for any reason, asthma, and unintentional injury … As a comparison, emergency care use for unintentional injury had been increasing before and during implementation … Among patients with hypertension, frequent in-person visits were associated with better blood pressure