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1061. Emergency Department and Catheter Insertion | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/ed-catheter-insertions-transcript.html
      December 01, 2017 - So because of his immobility, he developed a pressure ulcer on his sacrum and the physician decided to … Now we know the elderly are very vulnerable to infection and other injury in the hospital. … Possibly, the patient needs immobilization for trauma or surgery, patient is incontinent with open wounds … ; protocolized care for trauma; incontinence without open sacral or perineal wounds; pre-operative placement … On the next slide, we’ll – one case study is trauma.

1062. In Conversation With… Michelle Mello, MPhil, JD, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-michelle-mello-mphil-jd-phd
      July 01, 2017 - this area from personal acquaintance with physicians and understanding their narratives of how legal pressures … it would be useful for us to deliberate about what we think the value of different common types of injuries … That caring relationship doesn't end when an injury occurs, particularly if the injury is our fault. … They reduce the underlying safety problems that can lead to injuries that lead to claims. … Then, we have a few cases in which EHR systems themselves have had problems that have led to injuries

1063. A Unit Guide To Infection Prevention for Long-Term Care Staff | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/guides/infection-prevent.html
      March 01, 2017 - Infections cause pain, injury, disability, and sometimes even death, and can be very expensive to treat … signs, such as— Increased temperature Changes in respiration or pulse rate Changes in blood pressure … resident, if needed, that the law requires the use of safety lancets and needles to prevent needle stick injuries … Make sure that wounds are covered. Contain any urine, stool, or wound drainage. … An LTC facility must have negative pressure rooms and a respiratory fit-test program in order to safely

1064. Behavioral Counseling to Promote Physical Activity and a Healthful Diet to Prevent Cardiovascular Disease in Adults: A Systematic Review for the USPSTF (pdf file)
      www.uspreventiveservicestaskforce.org/home/getfilebytoken/bF5BNLvASN5r9EnP3VTJPN
      December 01, 2010 - The largest reduction in blood pressures oc- curred in 3 intensive salt-restriction counseling interven … Systolic and diastolic blood pressure were reduced by 1.5 and 0.7 mm Hg. … No increase in serious injuries occurred from phys- ical activity or unintended adverse changes in dietary … in overweight people with high-normal blood pressure. … Blood pressure, stroke, and coronary heart disease.

1065. Communication: Obstetric Hemorrhage - PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_3_communication.pptx
      July 01, 2023 - interruption to a doctor who is with a patient's family members. 2 Maternal and Perinatal Deaths and Injuries … 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 (i.e., the adequacy, … Her blood pressures have remained normotensive, and she has had good reflexes throughout the shift. … Her blood pressures have remained normotensive, and she has had good reflexes throughout the shift.” 

1066. 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

1067. 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

1068. 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

1069. 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

1070. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33588/psn-pdf
      March 15, 2025 - health care providers who are involved in an unanticipated adverse event, medical error, or patient injury … natural-history-recovery-healthcare-provider-second-victim-after-adverse-patient-events Stage of Recovery Summary Moving On Clinicians feel internal and external pressure

1071. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33578/psn-pdf
      September 15, 2024 - anesthesia were integral to the redesign of anesthesia equipment, significantly reducing the risk of injury … critical system property, reflecting the organization's capacity to bounce back in the face of continuing pressures

1072. 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?

1073. Appendix III (continued) | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apiiid.html
      June 01, 2010 - A few are related to the health and welfare of clients, such as injuries and medication errors. … HCBS MS Domains: Unmet Need Populations: Individuals with disabilities, adults with acquired brain injuries … information concerning the number of incidents (abuse and neglect; restraints, crimes against, serious injuries … required data via NCI form titled "NCI Protocol for Reporting Incidents: Abuse and Neglect, Serious Injuries … additional measures under development relate to influenza vaccinations for people with disabilities and pressure

1074. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49411/psn-pdf
      July 01, 2003 - On physical examination, her blood pressure was 145/85, pulse 85, oxygen saturation of 94%, with a respiratory … At this point, the patient’s blood pressure was 90/palpable with a heart rate of 40 and an O2 saturation … references https://psnet.ahrq.gov//#references https://psnet.ahrq.gov//#references level positive airway pressure … with uncertain outcomes, such as successful cardiac resuscitation with resultant severe anoxic brain injury

1075. Fatal Error in Neonate: Does "Just Culture" Provide an Answer? | PSNet
      psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
      June 24, 2020 - Were there time pressures, organizational or managerial expectations, or protocol or procedures that … October 14, 2009 Laparoscopic bile duct injury: understanding the psychology and heuristics

1076. 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.

1077. Behavioral Counseling Interventions to Promote a Healthy Diet and Physical Activity for CVD Prevention in Adults Without Known CVD Risk Factors: USPSTF Recommendation Statement (pdf file)
      www.uspreventiveservicestaskforce.org/home/getfilebytoken/HMSNGkJatRuN5VoVWfbuFL
      March 01, 2022 - prevented by ad- dressing modifiable risk factors, including smoking, obesity, diabe- tes, elevated blood pressure … prevented by addressing modifiable risk factors, including smoking, obesity, diabetes, elevated blood pressure … Adults 18 years or older without known CVD risk factors, which include hypertension or elevated blood pressure … adults 18 years or older without known CVD risk factors, which include hypertension or elevated blood pressure … intervention participants and control groups on any adverse events, serious ad- verse events, musculoskeletal injuries

1078. Disposition of Comments for Technical Brief 27 Patient Safety (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/ambulatory-safety_disposition-comments.pdf
      October 19, 2016 - We added this to the intro: Ambulatory providers experience intense time pressure, with current incentives … Again the extreme time pressures seem to be a big factor here and lack of time to both be fully attentive … injuries, patient falls, MRSA, undue radiologic testing (i.e., unnecessary and unwarranted duplicative … Cluttered environments, torn carpets, uneven flooring, exam table injuries (e.g., patients falling off … This also relates to above comments related to pace of work and production pressures.

1079. 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?”

1080. 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.