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121. Module 1: An Overview of the CANDOR Process | Agency for Healthcare Research and Quality
     www.monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes1.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

122. Module 3: Best Practices in Fall Prevention (doc file)
     www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module3/module3_fall-prevention.docx
     January 01, 2013 - Prevention Program Training Webinar Post-Fall Huddles: Reducing Preventable Falls and Fall-Related Injuries … medications or medicines that could cause sedation, confusion, impaired balance, or orthostatic blood pressure … The patient should be carefully and systematically assessed for injuries. … The post-fall clinical review focuses on immediate risk of injury or complications. … RCA is often used for a fall with injury.

123. Implementation Guide for the CANDOR Process | Agency for Healthcare Research and Quality
     www.monahrq.ahrq.gov/patient-safety/settings/hospital/candor/impguide.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 … Medicine (IOM) report, To Err Is Human: Building a Safer Health System , the problems associated with injury

124. Implement Teamwork and Communication for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.monahrq.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/implement-fac-guide.html
     July 01, 2023 - Slide 6: Root Causes of Maternal and Perinatal Deaths and Injuries 2004-2012 Say: Human factors … 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/

125. Module 4: How To Implement the Fall Prevention Program in Your Organization—Slide Presentation | Agency for Healthcare Research and Quality
     www.monahrq.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-4/slides.html
     September 01, 2017 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

126. Chapter 1: Background on Patient Safety and LEP Populations | Agency for Healthcare Research and Quality
     www.monahrq.ahrq.gov/health-literacy/professional-training/lepguide/chapter1.html
     September 01, 2020 - 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 … Near miss/close call * : An event or situation that did not produce patient injury, but only because … LEP patients are at greater risk of line infections, surgical infections, falls, and pressure ulcers

127. Ingestion of Illicit Substances Among Young Children Increased Significantly During COVID-19 Pandemic | Agency for Healthcare Research and Quality
     www.monahrq.ahrq.gov/news/newsletters/e-newsletter/861.html
     April 01, 2023 - The COVID-19 pandemic has intensified these pressures. … J Trauma Acute Care Surg 2023 Apr;94(5):592-8. Epub 2023 Nov 18. … Renal outcomes following intravenous contrast administration in patients with acute kidney injury: a

128. Module 2: Obtaining Organizational Buy-in and Support | Agency for Healthcare Research and Quality
     www.monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes2.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

129. Patient Safety Tools | Agency for Healthcare Research and Quality
     www.monahrq.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html
     June 01, 2022 - The Preventing Pressure Ulcers in Hospitals Toolkit assists hospital staff in implementing effective … pressure ulcer prevention practices through an interdisciplinary approach to care. … The toolkit draws on literature on best practices in pressure ulcer prevention and includes both validated … patients can suffer adverse outcomes and even fatal complications, and clinicians can be exposed to injury

130. Harnessing Data Visualization to Advance Equity in Clinical Services | Agency for Healthcare Research and Quality
     www.monahrq.ahrq.gov/challenges/data-visualization/index.html
     February 01, 2024 - higher prevalence of HIV in men who have sex with men), or socioeconomic factors (e.g., higher blood pressure … the Federal Government and its related entities, except in the case of willful misconduct, for any injury … whether direct, indirect, or consequential, arising from participation in this prize contest, whether the injury

131. Module 4: How To Implement the Fall Prevention Program in Your Organization—Training Guide | Agency for Healthcare Research and Quality
     www.monahrq.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-4/guide.html
     October 01, 2017 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … Critical Thinking for Fall Injury Prevention —AHRQ Fall Prevention Program Implementation Sharing Webinar

132. Implement-Facilitator-Guide (doc file)
     www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/implement/implement-facilitator-guide.docx
     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, Information … Example: The nurse says to the doctor, “Doctor, the patient’s blood pressure is dropping; it is 60/40

133. Introducing the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture: Webcast Transcript (pdf file)
     www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/ascwebinar/ascwebcast0715_transcript.pdf
     September 01, 2015 - our overall efforts in patient safety, and as part of the National Action Plan for health-associated injuries … Smith, Slide 23 And the area with the most room for improvement was Staffing, Work Pressure and Pace … Smith, Slide 25 The two bottom-performing items were from Staff Training and the Staffing, Work Pressure … And you can see that for Staffing, Work Pressure and Pace it was a 94 percent positive compared to a … Brown, Slide 44 Our second area of focus was Staffing, Work Pressure and Pace, and our result was 55

134. Comparison Tables for Making Healthcare Safer Reports | Agency for Healthcare Research and Quality
     www.monahrq.ahrq.gov/research/findings/making-healthcare-safer/comparison.html
     September 01, 2022 - Evidence (Not reviewed) (Not reviewed) Interventions To Prevent Contrast-Induced Acute Kidney Injury … Summary of Evidence Update (all patients) (Not reviewed) Preventing Patient Death or Serious Injury … Institutionalized Older People Summary of Evidence Update (all patients) (Not reviewed) Prevention of Pressure

135. Defining the New AHRQ: A Race for 21st Century Care | Agency for Healthcare Research and Quality
     www.monahrq.ahrq.gov/news/blog/ahrqviews/defining-new-ahrq.html
     January 01, 2021 - HAC events amount to more than $28 billion in excess healthcare costs, including pressure ulcers ($9.9 … nurses and other healthcare professionals remains a significant and troubling issue, as do workplace injuries

136. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
     www.monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.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

137. Mod5-Comm-Assessment (pdf file)
     www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-comm-assessment.pdf
     April 01, 2016 - Eventually, they are able to re-establish a normal heart rate, blood pressure, and adequate blood oxygen … During her procedure, her heart rate, blood pressure, and oxygen level were monitored. … During a part of the procedure, we became aware that her heart rate, blood pressure, and oxygen level … First off, right now Mary is stable; her heart rate, blood pressure, and oxygen level are all in normal … We also don’t know right now if she has suffered any injury from what happened, but we will check her

138. Overuse of Imaging for the Evaluation of Children with Simple Febrile Seizure: Final Report (pdf file)
     www.monahrq.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.

139. Implement Teamwork and Communication for Perinatal Safety (pdf file)
     www.monahrq.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

140. Appendix B: Bringing It To Life - Case Study | Agency for Healthcare Research and Quality
     www.monahrq.ahrq.gov/health-literacy/professional-training/lepguide/app-b.html
     September 01, 2020 - About 30 minutes later, he begins to develop some chest pressure, which he had not noticed before. … prevented the severe allergic reaction and allowed him to receive the angioplasty that could have prevented injury