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121. Ingestion of Illicit Substances Among Young Children Increased Significantly During COVID-19 Pandemic | Agency for Healthcare Research and Quality
     www.talkingquality.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

122. Module 2: Obtaining Organizational Buy-in and Support | Agency for Healthcare Research and Quality
     www.talkingquality.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

123. Patient Safety Tools | Agency for Healthcare Research and Quality
     www.talkingquality.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

124. Harnessing Data Visualization to Advance Equity in Clinical Services | Agency for Healthcare Research and Quality
     www.talkingquality.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

125. Module 4: How To Implement the Fall Prevention Program in Your Organization—Training Guide | Agency for Healthcare Research and Quality
     www.talkingquality.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

126. Implement-Facilitator-Guide (doc file)
     www.talkingquality.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

127. Introducing the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture: Webcast Transcript (pdf file)
     www.talkingquality.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

128. Comparison Tables for Making Healthcare Safer Reports | Agency for Healthcare Research and Quality
     www.talkingquality.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

129. Defining the New AHRQ: A Race for 21st Century Care | Agency for Healthcare Research and Quality
     www.talkingquality.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

130. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
     www.talkingquality.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

131. Mod5-Comm-Assessment (pdf file)
     www.talkingquality.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

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

133. Implement Teamwork and Communication for Perinatal Safety (pdf file)
     www.talkingquality.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

134. Best Practices in Fall Prevention
     www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module3/module3_slides_best-practices.pptx
     June 16, 2017 - number of medications that could cause sedation, confusion, impaired balance, or orthostatic blood pressure … Carefully assess patients for any injuries in a systematic way.

135. Appendix B: Bringing It To Life - Case Study | Agency for Healthcare Research and Quality
     www.talkingquality.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

136. Documentation of Heart Rate During Fluid Resuscitation for Children With Severe Sepsis or Septic Shock (pdf file)
     www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-232-fullreport.pdf
     June 01, 2018 - (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. … , central venous pressure, urine output, metabolic status, and peripheral perfusion (Rooney, Nadel, … 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

137. Primary Care Practice Facilitation Curriculum Module 31: Facilitating Panel Management (pdf file)
     www.talkingquality.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.

138. Global Assessment of Pediatric Patient Safety (GAPPS) Trigger Tool (pdf file)
     www.talkingquality.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

139. 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.talkingquality.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.

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