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1061. 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.

1062. 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.

1063. 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

1064. 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

1065. 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

1066. 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

1067. 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

1068. 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

1069. 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

1070. On-Time Preventable Hospital and Emergency Department Visits (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/2-preventablehospitalandedvisits-samplerpts_3.pdf
      November 30, 2013 - • Current clinical conditions contributing to transfer risk: use of oxygen, catheter or ostomy, any pressure … and skin, injury (fall related or not fall related), musculoskeletal, abnormal labs or anemia, fever … or skin issues • Fall-related injury • Non-fall-related injury • Abnormal labs • Fever/possible infection … disease • Asthma • Circulatory problems • Hypertension • Gastroenteritis • Angina pectoris • Falls/trauma … obstructive pulmonary disease, asthma, circulatory problems, hypertension, gastroenteritis, angina, falls/trauma

1071. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49774/psn-pdf
      November 01, 2016 - hospital course but was ultimately discharged to a rehabilitation facility with no major permanent injuries … a cervical laceration that extends beyond the vagina into the peritoneal cavity or a vaginal wall injury … (12) Furthermore, the operative field may appear dry during the procedure when the patient's blood pressure … is low, only to have significant bleeding later emerge when severe hypertensive pressures return, after

1072. Part 1: Overviews of the Report and the Hispanic Population | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/part1.html
      March 01, 2020 - For example, only half of people with high blood pressure have it controlled. … Leading causes of morbidity and mortality include heart disease, cancer, unintentional injuries, stroke

1073. Some Patients Can't Wait: Improving Timeliness of Emergency Department Care | PSNet
      psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care
      November 25, 2020 - Her vital signs included: blood pressure 154/113 mmHg, heart rate 75 beats/minute, respiratory rate 16 … Despite high levels of ED crowding, there is mounting pressure to see more patients in less time and … Patients with dangerous medical conditions and traumatic injuries may present with normal or near-normal … Multidisciplinary Simulation-Based Team Training for Trauma Resuscitation: A Scoping Review. … June 14, 2023 WebM&M Cases Under Pressure: Delayed

1074. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33764/psn-pdf
      April 01, 2014 - Does this accelerate the pressure to think about safety more broadly in the ambulatory environment and … That report called out the fact that many physical injuries are happening in the workforce, as well … as psychological injury due to lack of respect, bullying, fear, stress, and productivity pressures.

1075. A Real Heartache | PSNet
      psnet.ahrq.gov/web-mm/real-heartache
      October 01, 2018 - On physical examination, his initial blood pressure was elevated at 192/100 mm Hg, but his heart rate … Bilateral upper-extremity blood pressures were equal. … oral antacid/anesthetic combination) was given, and the patient reported symptom relief; his blood pressure … ECG interpretation: sinus tachycardia, with posterolateral injury pattern.

1076. Nursing-Staff-Shortages-Rapid-Research-Appendix-C (xls file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/nursing-staff-shortages-rapid-research-appendix-c.xlsx
      January 01, 2024 - Indicator QI Quality improvement RN registered nurse SD Standard deviation SOII Survey of Occupational Injuries … California's nurse-to-patient ratio law and occupational injury. … Hospital-acquired pressure ulcers decreased from 26 before the staffing change to 22 after the staffing … LOS also decreased with the addition of nurses for pressure ulcers and postoperative respiratory failure … Tarazi, 2020 Observational with comparison Policy: Medicaid expansion NR Hospitals under financial pressures

1077. 2019 National Healthcare Quality and Disparities Report Quality Trends (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr-core-measures-quality.pdf
      January 01, 2019 - 51.9% in 2013 67.7% in 2017 -9.5 0.006 Surgical Safety Home health care patients whose surgical wound … single measure that was not changing over time examines long-stay nursing home patients who experience injuries … Ulcers Short-stay nursing home patients with new or worsening pressure ulcers (MDS) 0.7% in 2013 … Ulcers High-risk, long-stay nursing home patients with pressure ulcer (MDS) 5.3% in 2013 4.8% in … 2017 -2.1 0.018 Falls Long-stay nursing home patients experiencing one or more falls with major injury

1078. Archived: Treatment: Evidence Summary: Gestational Diabetes Mellitus, Screening | United States Preventive Services Taskforce
      www.uspreventiveservicestaskforce.org/uspstf/document/treatment-evidence-summary/gestational-diabetes-mellitus-screening-january-2014
      May 28, 2013 - For other injury outcomes (that is, brachial plexus injury and clavicular fractures), results were inconsistent … Second, where reported, definitions of preeclampsia varied (for example, a blood pressure of 140/90 mm … apart, these criteria with laboratory measures indicative of preeclampsia, or an increase in blood pressure … because of heterogeneity 88 Cohort 2 515 −1.04 (−2.89 to 0.81) ‡ 8 Maternal birth trauma … 1 1030 0.35 (0.01 to 8.45) NA Cohort 1 389 0.02 (0.00 to 0.22) † NA Birth trauma

1079. “Copy and Paste” Notes and Autopopulated Text in the Electronic Health Records | PSNet
      psnet.ahrq.gov/web-mm/copy-and-paste-notes-and-autopopulated-text-electronic-health-record
      May 26, 2021 - On hospital day 2, the primary trauma surgery team ordered magnetic resonance imaging (MRI) of the brain … These studies, completed on hospital day 6, showed no evidence of traumatic or hypoxic brain injury and … no vertebral or ligamentous injury; the radiologist noted “minimal cervical spine epidural blood or … capturing data for quality metrics or responding to messages from patients through portals certainly add pressure … professional society educational efforts may be helpful in addressing this generational problem. 15 Pressure

1080. Unseen Perils of Urinary Catheters | PSNet
      psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
      January 31, 2024 - With regulatory and financial pressures directed toward reducing hospital-acquired infections, attention … They include dislodgement due to trauma, urethral erosion (traumatic hypospadias due to pressure necrosis … occurs more frequently in men who perform intermittent catheterizations frequently (e.g., spinal cord injury … J Wound Ostomy Continence Nurs. 2007;24:655-661. [go to PubMed] 2. … Assist in healing of open sacral/perineal wound in incontinent patients.