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561. Creating a Culture of Patient Safety through Innovative Hospital Design (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
     January 01, 2004 - Unfortunately, a small portion of errors do result in an “adverse event”—an injury caused by medical … For example, a 1991 Harvard Medical Practice Study reported that 69 percent of injuries suffered by … hospitalized patients in New York State in 1984 were the result of errors, and nearly 14 percent of these injuries … It may elevate blood pressure, increase pain, alter quality of sleep, and reduce overall perceived

562. Final Progress Report: Creating Safe Ambulatory Care: The Path to Resilience (pdf file)
     www.ahrq.gov/sites/default/files/2025-04/nemeth-report.pdf
     January 01, 2025 - exploratory study of ambulatory care settings was to identify and minimize or eliminate the potential for injuries … Time pressure can force clinicians to make decisions on insufficient or ambiguous information. … Patients who report shortness of breath (suggesting cardiac or pulmonary crises) or have suffered trauma

563. Webinar Transcript - The National Quality Strategy and the Public Sector: Federal Agency Alignment to the Six Priorities | Agency for Healthcare Research and Quality
     www.ahrq.gov/workingforquality/events/webinar-federal-agency-alignment-to-the-six-priorities.html
     November 01, 2016 - We work to prevent the leading cause of illness, injury, disability, and death. … We've displayed performance on the ABCs, which are appropriate aspirin use, blood pressure control, control … tobacco and got preventive care, we still have to address modifiable risk factors, including blood pressure … their profit according to the extent to which they're able to assist their members in controlling blood pressure

564. Ratio of Magnetic Resonance Imaging Scans to Computed Tomography Scans for the Evaluation of Children with Atraumatic Seizure: Report (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0197-fullreport.pdf
     November 01, 2019 - These complications include compromised airway, hypoxia leading to central nervous system injury, and … moderate and deep sedation carry risk of airway compromise, hypoxia resulting in central nervous system injury … These risks include dental trauma; airway edema (swelling of the windpipe); vocal cord spasm or injury … ; regurgitation of stomach contents with subsequent aspiration (inhalation) pneumonia; injury to arteries … , veins, or nerves; alterations in blood pressure; and/or irregular heart rhythms (Society for Pediatric

565. Final Progress Report: Pursuing Perfection in Pediatric Therapeutics (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/lannon2-report.pdf
     January 01, 2024 - Predict and prevent nephrotoxic medication-associated acute kidney injury in noncritically ill hospitalized … Electronic Health Record Identification of Nephrotoxin Exposure and Associated Acute Kidney Injury. … -55 27803957 2017 NPC-QIC Improvement/outcomes Frank G, Walsh KE, Wooton S, et al Impact of a Pressure … Injury Prevention Bundle in the Solutions for Patient Safety Network Pediatric quality & safety

566. Patient Safety Organizations: A Summary of 2014 Profiles (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-portfolios-summary-profile-2014.pdf
     January 01, 2014 - The term safety refers to reducing risk from harm and injury, whereas the term quality suggests striving … Information Form, and Summary of Initial Report Form) and then applying Common Formats for falls, pressure

567. Prescribers-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/prescribers-facilitator-guide.docx
     June 01, 2021 - unanticipated event in a health care setting resulting in death or serious physical or psychological injury … Half of the respondents in that study reported feeling pressure to give a medication for which they questioned

568. Screening for Asymptomatic Carotid Artery Stenosis, Evidence Synthesis, No. 50 (pdf file)
     www.ahrq.gov/downloads/pub/prevent/pdfser/cas/cases.pdf
     December 01, 2007 - Although it is difficult to determine the intensity of medical management, the mean systolic blood pressure … However, among the RCTs, the VACS reported surgical complications rates of 3.8% for cranial nerve injuries … (none of these injuries were permanent), 5.2% for hypotension, and 25% for hypertension.40 Is … Cumulative effects of high cholesterol levels, high blood pressure, and cigarette smoking on carotid … Overall = 3.7% High volume hospital (>100 cases/year) = 3.5% Low volume hospital = 5.2% 3% HTN 2% wound

569. Learning from Errors in Ambulatory Pediatrics (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Mohr.pdf
     February 01, 2004 - Because of the age of pediatric patients, when an error leads to injury it may have an impact on the … No complete loss of consciousness -- mom caught him with no head injury sustained. … post-term newborn infant with mild respiratory distress syndrome requiring continuous positive airway pressure … The occurrence of an error did not imply harm or injury to the patient.

570. Chartbook on Women's Health Care: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/womenhealth/womenh-slides.html
     March 01, 2020 - Importance: About 70 million American adults (29%) have high blood pressure ( Nwankwo, et al., 2013 … High blood pressure costs the Nation $46 billion each year. … mostly attributable to sudden unexpected infant death (SUID), congenital anomalies, infection, and injury … Web-based Injury Statistics Query and Reporting System (WISQARS) [Online] (2013). … http://www.cdc.gov/injury/wisqars/index.html . Accessed September 1, 2015.

571. Final Progress Report: Risk Analysis of Pediatric Chemotherapy Processes (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/shenep-report.pdf
     January 01, 2024 - Review effectiveness of 60%. 6 Significant effect/ Minor injury Actual error occurred and reached … Page 8 8 Extreme effect/major injury Actual error occurred and reached the patient. … Error would result in a major injury for the individual served, including permanent patient harm … detect Remote likelihood that current controls will detect. 10 Catastrophic effect; terminal injury … Discussion Although CPOE is supported philosophically by multiple groups that exert significant pressure

572. Chartbook on Effective Treatment: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/chartbooks/effectivetreatment/effectivetreatment-slides.html
     April 01, 2018 - Most Costly Conditions, 2013 Condition Total Expenses (Millions) Report Section Trauma-related … Blood pressure under control is defined as having a mean systolic blood pressure <140 and mean diastolic … blood pressure <90 among all hypertensive patients. … , blood pressure control among people with diagnosed high blood pressure remains a problem. … Increased risk of death from car crashes and other injuries.

573. Final Progress Report: Process Reliability and Organizational Learning in Home Health Care (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/silver-report.pdf
     January 01, 2025 - Two hospitalizations (1.5%) were the result of injuries that were unrelated to home care. … 120 Decline resulting from patient's condition Complication of earlier care New diagnosis Injury … benefit will be provided in those visits (e.g., an agency cannot simply increase the frequency of wound … Identifying barriers to reporting changes in condition: unclear expectations, time/production pressure

574. Meeting Minutes, November 2017 | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/events/nac/2017-11-nac/nacmtg1117-minutes.html
     February 01, 2018 - Preliminary data on the use of the training materials showed significant decreases in falls with injury … AHRQ also released training materials for preventing pressure ulcers in hospitals. … Preliminary data on use of the materials showed significant decreases in pressure ulcers during a 1-year

575. Slide 1 (ppt file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/preventing-cauti-engaging-clinicians-051413.ppt
     January 01, 2013 - Reduce antibiotic use Reduce potential of increased resistance and Clostridium difficile disease Reduce trauma … (mechanical complications): Metal and urethral injury Hematuria Hospitalists Geriatricians Infectious … Inappropriate urinary catheter use may negatively affect the surgeon’s profile Risk of infection and trauma … They may lead to urinary tract infections and cause mechanical trauma to the urethra and bladder. … They also immobilize patients—increasing the likelihood of pressure ulcers, falls and prolonged inpatient

576. Methods (continued, 2) | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamily3a.html
     July 01, 2018 - External motivation may also come from pressures or "pushes" from external organizations. … hospital-associated infections, reducing risk of harm from patient falls, and preventing hospital-associated pressure … unanticipated event in a health care setting resulting in death or serious physical or psychological injury … level (e.g., on PFACs and decisionmaking committees). 103,104 Sentinel events also lead to external pressures

577. Chartbook on Hispanic Health Care: Slide Presentation—Part 3 | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/hisph-slides-pt3.html
     May 01, 2018 - Slide 10 Adults who needed care right away for an illness, injury, or condition in the last 12 months … ) among Hispanics, 2002-2012 Image: Graphs show adults who needed care right away for an illness, injury … Slide 11 Children who needed care right away for an illness, injury, or condition in the last 12 … restrained daily can become weak, lose their ability to go to the bathroom by themselves, and develop pressure … Importance: Many patients who receive home health care are recovering from an injury or illness and

578. 2023 National Healthcare Quality and Disparities Report Appendixes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023-NHQDR-appendixes-ACDE.pdf
     January 01, 2023 - 1,000 elective-surgery admissions, age 18 and over HCUP 2020 Reclosure of postoperative abdominal wound … 2020 Home health care patients whose management of oral medications improved OASIS 2021 Birth trauma … stages 2-4 pressure ulcer or unstageable pressure ulcer MDS 2021 Low-risk, long-stay nursing home … 2020 Home health care patients whose management of oral medications improved OASIS 2021 Birth trauma … stages 2-4 pressure ulcer or unstageable pressure ulcer MDS 2021 Low-risk, long-stay nursing home

579. 2022 National Healthcare Quality and Disparities Report Appendixes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2022qdr-appendix-combined.pdf
     October 25, 2022 - HCUP 2019 Home health care patients whose management of oral medications improved OASIS 2020 Birth trauma … pressure ulcer MDS 2019 Low-risk, long-stay nursing home residents with a catheter inserted and left … MDS 2019 Short-stay nursing home patients with pressure ulcers that are new or worsened MDS 2018 … HCUP 2019 Home health care patients whose management of oral medications improved OASIS 2020 Birth trauma … MDS 2019 Short-stay nursing home patients with pressure ulcers that are new or worsened MDS 2018

580. 2023 National Healthcare Quality and Disparities Report Appendixes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023-NHQDR-appendixes-ACDE-rev.pdf
     January 01, 2023 - 1,000 elective-surgery admissions, age 18 and over HCUP 2020 Reclosure of postoperative abdominal wound … 2020 Home health care patients whose management of oral medications improved OASIS 2021 Birth trauma … stages 2-4 pressure ulcer or unstageable pressure ulcer MDS 2021 Low-risk, long-stay nursing home … 2020 Home health care patients whose management of oral medications improved OASIS 2021 Birth trauma … stages 2-4 pressure ulcer or unstageable pressure ulcer MDS 2021 Low-risk, long-stay nursing home