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461. AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety.pptx
     May 01, 2017 - fetal criteria for procedures that increase risk for cord prolapse47 such as— amniotomy intrauterine pressure … Effects of shoulder dystocia training on the incidence of brachial plexus injury. … Shoulder dystocia and injuries: prevention and management.

462. “Near-miss” Reporting System Development and Implications for Human Subjects Protection (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Murff.pdf
     January 01, 2004 - Several case reports suggest that these extrinsic risks do, in fact, exert significant pressures on … near miss” represents the identification of a potential safety problem, prior to it resulting in an injury … Typically the same system failures that might have resulted in an injury also are present in a near … patient safety can be improved by identifying latent failure prior to the occurrence of a catastrophic injury … Because an injury has not occurred, liability is limited.

463. 3. Results | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state3.html
     January 01, 2024 - that patients with diagnosis-related claims were  2.33 times more likely to die than to have a minor injury … have been associated with increased medical errors and stress, anxiety, and burnout. 113,114 Time pressure … of diagnostic safety found the need to prioritize research on system factors, such as workload, time pressure … considering alternative diagnoses, taking a diagnostic timeout to pause and reflect, and minimizing time pressures … themes of the diagnostic process, including diagnosis as a social phenomenon and distractions and time pressures

464. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/handouts.html
     September 01, 2017 - Report data help identify residents with new ADL decline, fall risk, or fall injury, therefore at risk … and Rehab  Managers Weekly huddle to review residents at risk for ADL decline or fall or with fall injury … with stage 2 or above pressure ulcers at risk for infection who potentially require hospitalization/ … Reports provide information about current and changing risks for pressure ulcer healing and can aid root … Discharge diagnoses were dehydration, fall with injury, cellulitis, and angina.

465. Advancing Patient Safety: A Decade of Evidence, Design, and Implementation (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/advancing-patient-safety.pdf
     January 01, 2010 - private-public partnerships to: (1) identify the causes of preventable health care errors and patient injury … By using hospital administrative data, PSIs can identify pressure ulcers, postoperative pulmonary … Education in 2003 and that the long shifts medical interns worked led to 61 percent more needlestick injuries

466. Advancing Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/advancing/index.html
     July 01, 2022 - private-public partnerships to: (1) identify the causes of preventable health care errors and patient injury … By using hospital administrative data, PSIs can identify pressure ulcers, postoperative pulmonary emboli … Education in 2003 and that the long shifts medical interns worked led to 61 percent more needlestick injuries

467. Development of a Screening Tool for Safe Wheelchair Seating (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Gavin.pdf
     January 01, 2001 - systems do not fit the individual needs of nursing homes residents, many problems can become evident: pressure … diagnosis, cognitive status, communication ability, sensation level, skin integrity (presence/absence of pressure … reductions (e.g., staff time saved if residents could self-propel, elimination of repositioning needs, injury … Nursing home wheelchair users: seat comfort and peak pressures [unpublished doctoral thesis].

468. The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Faltz_56.pdf
     March 27, 2008 - identification, orientation/training, use of available information, site marking, “time out,” and time pressures … Although a minority of these events result in significant harm to patients,1 major injuries and death … • Production/time pressures, including case urgency.

469. Adaptation of AHRQ Patient Safety Indicators for Use in ICD-10 Administrative Data by an International Consortium (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Quan_52.pdf
     March 10, 2008 - 10 specifies certain conditions in more detail than ICD-9-CM by adding anatomical sites and type of injury … Major diagnosis category (MDC) exclusion Procedure codes requirement PSI 14: Postoperative wound … – injury to neonate Yes All liveborn births (newborns) No No PSI 18: Obstetric trauma – vaginal … the ulcer, while M70 codes describe unspecified “soft tissue disorders related to use, overuse, and pressure … Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization

470. Improving Safety Using Teamwork and Patient Safety Norms (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/teamwork-ptsafety-norms-slides.pdf
     June 30, 2025 - Implementation of TeamSTEPPS at a Level-1 Military Trauma Center: The San Antonio Military Medical … hospital-acquired infection was reviewed using LFD ► LFD used for post-fall huddle and after skin injury … Skin: Pressure Ulcer? POA? - Current descript ion of PU 10. Foley: Can it be removed?

471. Protocol for Identifying and Treating Children With Sepsis Syndrome in the Emergency Department (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-228-fullreport.pdf
     February 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 6 blood pressure until the advanced stages of … 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 … requirement for diagnosis of septic shock in children; in fact, shock may occur long before blood pressure

472. The Nature, Characteristics and Patterns of Perinatal Critical Events Teams (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Riley_58.pdf
     April 02, 2008 - remains high at 6.3 birth traumas per 1,000 live deliveries.13 • Team and leadership communication … Discussion Critical event teams in health care face significant complexity and time pressures, which … Preventing infant death and injury during delivery. Sentinel Event Alert; Issue 30. … An evaluation of trauma team leader performance by video recording. … Video techniques and data compared with observation in emergency trauma care.

473. Findings From the AHRQ Transforming Primary Care Grant Initiative: A Synthesis Report (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/tpc/tpc-synthesis-report.pdf
     July 22, 2015 - post-implementation period.33 The trend applied to emergency care use overall and to asthma and unintentional injury … Specifically, the percent of PCMH patients hospitalized per month (overall and for asthma and unintentional injury … Donahue, MD, MPH Diabetes • HbA1c <9% • LDL cholesterol <100 mg/dL • Blood pressure <130/80 … ≤130/80 mm Hg • LDL cholesterol ≤100 mg/dL Cardiovascular disease: • Blood pressure ≤130/80 … Gabbay, MD, PhD Diabetes • HbA1c <7% • Blood pressure <130/80 mm Hg • LDL cholesterol <100

474. Imp-Handouts (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/imp-handouts.pdf
     June 02, 2025 - Report data help identify residents with new ADL decline, fall risk, or fall injury, therefore at risk … Rehab Managers Weekly huddle to review residents at risk for ADL decline or fall or with fall injury … 2 or above pressure ulcers at risk for infection who potentially require hospitalization/ED visit … Reports provide information about current and changing risks for pressure ulcer healing and can aid … Discharge diagnoses were dehydration, fall with injury, cellulitis, and angina.

475. Presentation: Optimize Your Briefings and Debriefings
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_opt_briefings.pptx
     December 01, 2017 - defines a sentinel event as an unexpected occurrence involving death or serious physical or psychological injury … Serious injury specifically includes loss of limb or function. … Confirm patient identity, site, and procedure Review perfusion plan, including– Cannulation Perfusion pressure … Review the perfusion plan, including cannulation, perfusion pressure goals, temperature, and transfusion … for improvement Ask if instrument, sponge, and needle counts are correct Record name of procedure and wound

476. Case 2. Central Hospital | Agency for Healthcare Research and Quality
     www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-case2.html
     November 01, 2014 - Participation is required in the following priority areas: falls and fall injuries, pressure ulcers, … For example, in 2008 the national system launched a campaign to have zero preventable injuries or deaths … , the department was working toward certification as an American College of Surgeons (ACS) Level II Trauma … The ED successfully launched a trauma center and identified a new director in early 2010. … Staff perceived a shift of work to other staff because of the pressures of Lean process.

477. Technology for Improving Medication Monitoring in Nursing Homes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Lapane.pdf
     March 09, 2005 - Activities Falls* Nutritional status Dehydration Dental care Feeding tubes† Physical restraints† Pressure … Factors associated with serious injury during falls by ambulatory nursing home residents. … Fall injuries in the elderly. Clin Geriatr Med 1985;1(3):501–12. 28. Monane M, Avorn J.

478. Final Progress Report: Quality Factors in Nursing Home Choice (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/congdon-magilvy-report.pdf
     January 01, 2024 - homes include indicators of physical care, such as rate of restraint use (physical and chemical), pressure … sore prevalence, urinary tract infections, pain, injuries, hospitalizations, functional decline; staffing … follows: .626 for urinary tract infections, .528 for weight loss, .853 for tube feeding, .570 for pressure … indicated that NHs with higher total hours of care had higher rates of urinary tract infections and pressure

479. Final Progress Report: Human Factors and Systems Integration in High Technology Surgery (HF-SIgHTS) (pdf file)
     www.ahrq.gov/sites/default/files/2025-07/catchpole-report.pdf
     January 01, 2025 - model of the mechanisms by which small seemingly innocuous events escalate to create serious surgical injuries … verbal communication which is already the most frequently cited cause of procedural error and surgical injury … separation among members of the OR team, new anesthesia strategies, coordination and communication pressures … verbal communication which is already the most frequently cited cause of procedural error and surgical injury … primarily applied in surgery, comparable research has been successfully conducted in other venues such as trauma

480. Urine Culturing Stewardship in the ICU Setting Facilitator Notes
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urine-culturing.pptx
     April 01, 2022 - Abbreviations: BP = blood pressure; GI = gastrointestinal; Hgb = hemoglobin; HR = heart rate; ICU = intensive … without evidence of another source on history, physical examination, or laboratory testing In spinal cord injury … Has the patient had recent urologic manipulation such as trauma to the GU tract or surgery? … Effectiveness of a bundled approach to reduce urinary catheters and infection rates in trauma patients