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141. Global Assessment of Pediatric Patient Safety (GAPPS) Trigger Tool (pdf file)
     www.healthcare411.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

142. Timely Antibiotics for Children With Severe Sepsis or Septic Shock (pdf file)
     www.healthcare411.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

143. Timely Fluid Bolus for Children With Severe Sepsis or Septic Shock (pdf file)
     www.healthcare411.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

144. 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.healthcare411.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.

145. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
     www.healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
     August 01, 2022 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … The event review focuses on uncovering latent hazards or contributing factors that increase pressure

146. AHRQ Transforming Primary Care Grants | Agency for Healthcare Research and Quality
     www.healthcare411.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

147. AHRQ Transforming Primary Care Grants Bibliography | Agency for Healthcare Research and Quality
     www.healthcare411.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

148. Protocol for Identifying and Treating Children With Sepsis Syndrome in the Emergency Department (pdf file)
     www.healthcare411.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

149. Findings From the AHRQ Transforming Primary Care Grant Initiative: A Synthesis Report (pdf file)
     www.healthcare411.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

150. Advancing Patient Safety | Agency for Healthcare Research and Quality
     www.healthcare411.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

151. Ratio of Magnetic Resonance Imaging Scans to Computed Tomography Scans for the Evaluation of Children with Atraumatic Seizure: Report (pdf file)
     www.healthcare411.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

152. 2023 National Healthcare Quality and Disparities Report Appendixes (pdf file)
     www.healthcare411.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

153. Cesarean Delivery for Nulliparous (NTSV) Women (Appropriate Use) (pdf file)
     www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/perinatal/chipra-0082-fullreport.pdf
     March 01, 2016 - delivery are at much higher risk for rehospitalization for uterine infection and obstetrical surgical wound … nonmedical factors such as provider density, the capacity of the local health care system, and malpractice pressure … o Have a physical abnormality or injury to their brain or spinal cord. … For example, there may be fewer surgical injuries and fewer infections. … vaginally is more likely to have a nerve injury that affects the shoulder, arm, or hand.

154. Meeting Minutes, November 2017 | Agency for Healthcare Research and Quality
     www.healthcare411.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

155. Fall Prevention Toolkit (doc file)
     www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module2/module2_tools.docx
     November 16, 2011 - Monthly falls analysis by: location and time of fall shift and day of week type of injury … consequences of falls High-risk medications, sleep hygiene measures for management of anxiety Low blood pressure

156. 2017Qdr-Patsafchartbook (pdf file)
     www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/2017qdr-patsafchartbook.pdf
     October 01, 2018 - per 1,000 instrument-assisted deliveries • Birth trauma - injury to neonate per 1,000 selected live … 40 60 80 100 2014 2015 2016 2017 2018 2019 GOAL Ra te p er 1 ,0 00 D is ch ar ge s Pressure … 40 60 80 100 2014 2015 2016 2017 2018 2019 GOAL Ra te p er 1 ,0 00 D is ch ar ge s Pressure … Adverse Drug Events • An adverse drug event (ADE) is an injury—including physical harm, mental harm, … The home health team should regularly change wound dressing and teach the patient about wound care.

157. Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals (pdf file)
     www.healthcare411.ahrq.gov/sites/default/files/publications/files/lepguide.pdf
     September 01, 2012 - Adverse event*: Any injury caused by medical care. … include pneumothorax from central venous catheter placement, anaphylaxis to penicillin, postoperative wound … Similarly, postoperative wound infections count as adverse events even if the operation proceeded with … Teamwork training improves the clinical care of trauma patients. … About 30 minutes later, he begins to develop some chest pressure, which he had not noticed before.

158. Catheter Ablation for Atrial Fibrillation: Topic Refinement - Project ID: CRDT0913 (pdf file)
     www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/afib_topicref.pdf
     January 01, 2020 - peripheral vascular complication [including pseudoaneurysm, hematoma at catheter insertion site, vascular injury

159. Executive Summary | Agency for Healthcare Research and Quality
     www.healthcare411.ahrq.gov/health-literacy/professional-training/lepguide/exec-summary.html
     September 01, 2020 - not be harmed by the care that is intended to help them, and they should remain free from accidental injury … admissions and/or discharge. 68 Greater risk of line infections, surgical infections, falls, and pressure

160. 2019 National Healthcare Quality and Disparities Report Data Sources (pdf file)
     www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr-datasources.pdf
     December 01, 2020 - state-specific data on preventive health practices and risk behaviors linked to chronic diseases, injuries … The examination includes physical measurements, such as blood pressure and dental examinations, and … from each family in the house and collects data on topics including health status and limitations, injuries … infections; seven types of adverse events associated with surgery; patient falls; and hospital-acquired pressure … events associated with the hospital stay and not present on hospital admission (inpatient falls and pressure