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1041. Preventing Perioperative Medication Errors and Adverse Drug Events Through the Use of Clinical Decision Support - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/k08hs24764-nanji-final-report-2022.pdf
      January 01, 2022 - The CDS group practiced tighter blood pressure control, which has been shown to prevent end-organ … damage, such as acute myocardial injury and renal injury. … proposed medication) or reminder alerts (eg, reminders to treat hypotension at individualized blood pressure … in a workflow that is faster, more efficient, and leads to higher quality of care (tighter blood pressure … clinician task time by 20% (see Table 1), improving efficiency and quality of care metrics (blood pressure

1042. Appendix A, Pt. 2 | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/stpra/stpraapa2.html
      April 01, 2018 - Other risk factors were male sex (OR 2.01, 95% CL 0.44-10.45), injury-operation interval less than … The incidence increased from 13.2% in clean wounds to 70.0% in dirty wounds. … for specific operation Intraoperative recommendations Ventilation Maintain positive-pressure … Risks include effusions (12% or procedures), deep vein thrombosis (1.8%-46%), nerve injuries, and arterial … injury or aneurysm formation.

1043. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50389/psn-pdf
      September 25, 2019 - Laboratory tests showed acute kidney injury with markedly elevated levels of potassium, phosphate, and … The patient's blood pressure improved with fluids. … Six hours after admission, the patient's blood pressure started to drop, requiring further intravenous … Despite aggressive measures to maintain her circulation, blood pressures further dropped, and a code

1044. Slide 1 (pdf file)
      hcup-us.ahrq.gov/datainnovations/clinicaldata/MPinepresentation.pdf
      September 22, 2010 - For accidents (i.e., E codes), POA codes are based on the relation of the time of injury to the time … Therefore, POA=Y only when injury occurs prior to admission. … Composite Scores Enter 4 or More Models Vital Signs, Other Lab Data, Scores • Pulse (8) • Blood Pressure

1045. Final Progress Report: Health Journalism 2011, national conference on healthcare journalism (pdf file)
      www.ahrq.gov/sites/default/files/2024-05/bruzzese3-report.pdf
      January 01, 2024 - Soldiers with traumatic brain injuries. Athletes with concussions. … care o From pee wee to pro: Head injuries in sports o Can the FDA ensure food safety? … Journalism Graduate Program • How nanotechnology may revolutionize the detection of traumatic brain injury … interim deputy director, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury … "Sim Man" and "Harvey" reproduced physiological signs, such as blood pressure and heart and breathing

1046. Module 3. Falls Prevention | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mgdod3.html
      October 01, 2014 - In addition, they should be able to manage injuries that result from falls. … Risk factors are identified, and ways to prevent injury are discussed. … Develop participants' knowledge and skills in preventing falls and fall-related injuries. … He has moderate dementia, and his blood pressure falls when he stands up too fast, making him dizzy. … Paul comes to visit his father after work; he is aware that his father fell yesterday, without injury

1047. The Effect of Dietary Digestible Carbohydrate Intake on Risk of Cardiovascular Disease (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/risk-cardiovascular-disease.pdf
      January 01, 2023 - metabolism, cancer, and malabsorption syndromes • Participants hospitalized with an illness or injury … Association of dietary nutrients with blood lipids and blood pressure in 18 countries: a cross-sectional … Effect of high-carbohydrate or high- monounsaturated fatty acid diets on blood pressure: a systematic … Effect of a high-carbohydrate versus a high--cis- monounsaturated fat diet on blood pressure in patients … Effects of protein, monounsaturated fat, and carbohydrate intake on blood pressure and serum lipids:

1048. Acute Care Learning From Defects
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/changes-slides.pptx
      November 01, 2019 - associated with biliary duct obstruction from a gallstone Temperature of 101° F, pulse of 100, and blood pressure … Acute kidney injury and unnecessary lab tests and imaging could have been avoided 3 Piperacillin/tazobactam … Care Learning From Antibiotic-Associated Adverse Events Adverse event: Patient develops acute kidney injury

1049. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.341_slideshow.ppt
      March 01, 2015 - surgery is a sentinel event—an unexpected occurrence involving death or serious physical or psychological injuries … Incorrect or lack of consent Failure to use site markings Surgeon fatigue Multiple surgeons Unusual time pressures

1050. The Safety of Medical Devices | PSNet
      psnet.ahrq.gov/perspective/safety-medical-devices
      June 01, 2011 - While the team adjusted the table, it swung loose and the patient fell to the floor but sustained no injury … analysts who see this behavior as a universal law: automobile seat belts actually do reduce deaths and injuries … So I think the combination of a high frequency of alarms and pressure for productivity is potentially … In studying some of the recent mine accidents, I found there was an institutional pressure there to have … come not because people are greedy or selfish or that they don't care, but that their bias and the pressures

1051. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery. | PSNet
      psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emergency-cesarean-delivery
      November 25, 2020 - Vital signs showed systolic blood pressure around 90 mm Hg, mean arterial pressure (MAP) 60-70, pulse … At that time, the patient’s vital signs showed a blood pressure of 88/40, mean arterial pressure of 57 … include increased blood volume, increased cardiac output, decreased vascular resistance (with lower blood pressure … For example, single parameter alerts such as a diastolic blood pressure >90 mm Hg were common in the … October 30, 2024 WebM&M Cases Uterine Artery Injury during

1052. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49522/psn-pdf
      November 01, 2006 - Mostly in response to increasing pressure from the hospital's administration to improve compliance with … Intramuscular injection site injuries masquerading as pressure ulcers. Wounds. 2003;15:302-312.

1053. The National Action Alliance to Advance Patient Safety Summer Webinar Series - PowerPoint Presentation (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/public-action-alliance-slides-040323_LOCKED.pdf
      May 25, 2023 - factors focus areas • Workplace Change Collaborative – National Framework on Burnout and Moral Injury … “By and large, the U.S. does not account for medical care injuries and deaths in our vital statistics … Where it should say 'medical care harm/injuries', it's blank. … as surge … our new normal *Healthcare Acquired Infections, Early Elective Deliveries, Falls with Injury … , Healthcare Acquired Pressure Injuries, NTSV C-Section patients to get to WHO Goal, Sepsis Mortality

1054. Comparative Effectiveness of Pain Management Interventions fo Hip Fracture (ppt file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/hip-fracture-pain.ppt
      May 01, 2011 - also includes bone-anchored [skeletal] traction) performed to stabilize the fractured leg and relieve pressure … practices, and products that are not part of conventional medicine, such as: Acupressure: applying pressure … Acupressure uses applied pressure at body points away from the location of pain to lessen pain. … , which lasts for the duration of injury and healing. … lasts for the duration of injury and healing.

1055. Comparative Effectiveness of Pain Management Interventions fo Hip Fracture (ppt file)
      effectivehealthcare.ahrq.gov/sites/default/files/hip-fracture-pain.ppt
      May 01, 2011 - also includes bone-anchored [skeletal] traction) performed to stabilize the fractured leg and relieve pressure … practices, and products that are not part of conventional medicine, such as: Acupressure: applying pressure … Acupressure uses applied pressure at body points away from the location of pain to lessen pain. … , which lasts for the duration of injury and healing. … lasts for the duration of injury and healing.

1056. In Conversation With… Leah Binder, MA, MGA | PSNet
      psnet.ahrq.gov/perspective/conversation-leah-binder-ma-mga
      February 26, 2025 - reason for us to make sure, at least from Leapfrog's spot, that there's a continued laser focus and pressure … We graded every hospital for which there's adequate data on errors, accidents, and injuries. … Then hopefully they will go to the hospital and put some pressure on them to elevate the priority of … How do I protect them from the errors and injuries that are rampant? What can I do better?

1057. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality | PSNet
      psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
      October 01, 2004 - Mostly in response to increasing pressure from the hospital's administration to improve compliance with … Intramuscular injection site injuries masquerading as pressure ulcers. Wounds. 2003;15:302-312.

1058. Treatments for Fecal Incontinence: A Review of the Research for Adults (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/fecal-incontinence_consumer.pdf
      July 01, 2016 - surgery involving the rectum or anus, or straining often to pass stool. » A spinal cord or brain injury … A tear can be caused by childbirth or injury. … ) Anal sphincter replacement �� Infection ��Sepsis† ��Leaking or other problems with the surgery wound … This could lead to blood clots and leaky blood vessels, very low blood pressure, and damage to your

1059. Whole-Body Vibration Therapy for Osteoporosis (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/osteoporosis-vibration-therapy_technical-brief.pdf
      January 01, 2020 - Pharmacological interventions can result in adverse outcomes, commonly minimal trauma atypical fractures … weight-bearing exercise, may also increase bone density18,19 and may be safer than medication, but risk of injury … discontinuation in 10-15 percent of patients.59 Common adverse effects from bisphosphonates include minimal trauma … Women were excluded from these studies if they had any number of conditions such as high blood pressure … They may also experience other side effects while using the platform, such as decreased blood pressure

1060. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846170/psn-pdf
      March 15, 2023 - confusion, the patient ran out of his medication and his daughter and home health nurse noted poor blood pressure … This lapse resulted in poor blood pressure control, but fortunately no harmful outcomes. … errors have the potential to be serious and may result in adverse drug events (ADE), which are patient injuries … What changes you will make to your blood pressure medications?”