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1101. Code Status Confusion | PSNet
      psnet.ahrq.gov/web-mm/code-status-confusion
      September 01, 2006 - 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 … s preference to avoid invasive ventilation, she was started on noninvasive bi-level positive airway pressure … with uncertain outcomes, such as successful cardiac resuscitation with resultant severe anoxic brain injury

1102. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. | PSNet
      psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
      January 29, 2021 - When continuous positive airway pressure is prescribed for sleep apnea for these patients, it may not … anesthetic with an endotracheal tube was therefore necessary in this case so that positive end expiratory pressure … so quickly. 24 Inserting an airway, applying high flow nasal oxygen or continuous positive airway pressure … April 24, 2024 WebM&M Cases Uterine Artery Injury

1103. Care Coordination Quality Measure for Primary Care (CCQM-PC) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/coordination/ccqmpc/ccqm-pc-survey-instructions.pdf
      July 01, 2016 - most of your usual health care needs and who you normally see when you need care for a new illness or injury … being able to walk a flight of stairs without losing your breath, or target rates—for example, a blood pressure … In the last 12 months, if you had an illness or injury, how often did your primary care provider or … 1 Never 2 Sometimes 3 Usually 4 Always 5 I did not have an illness or injury in the last … High blood pressure or hypertension? Congestive heart failure? Coronary artery disease?

1104. ___APS-Def_Public.book (pdf file)
      hcup-us.ahrq.gov/db/nation/nis/APS-DRGsDefManualV25Public.pdf
      June 01, 2009 - Ventilation - < 96 Hours 9672 Continuous Mechanical Ventilation - 96+ Hours 9390 Continuous Positive Airway Pressure … 902 901 WD DBRD FOR INJURIES 903 901 WD DBRD FOR INJURIES … 904 904 SKN GRFTS FOR INJURIES 905 904 SKN GRFTS FOR INJURIES … INJURIES 908 907 OTH OR PX FOR INJURIES 909 907 OTH OR … PX FOR INJURIES 913 0-17 AGE SPLIT 913 TRAUMATIC INJURY 914 0-17 AGE

1105. Research Themes and Findings | Digital Healthcare Research
      digital.ahrq.gov/program-overview/research-reports/2022-year-review/research-themes-and-findings
      January 01, 2022 - standards-based shareable, interoperable patient-facing clinical decision support tool for high blood pressure … empowering patients and providing them the tools to better engage in the self-management of their high blood pressure … reduce the need for opioids, and improve outcomes for children needing at-home dressing changes for burn injuries

1106. Do Transient Working Conditions Trigger Medical Errors? (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Grayson.pdf
      January 01, 2003 - .6, 10–12 Injuries to workers result from a causal chain of events involving both latent and immediate … Indeed, many risk factors for injury that have been studied in case-crossover studies of injury are … circumstances may be the result of other working conditions, such as a hectic work environment, time pressures … Case-crossover studies of occupational trauma: methodological caveats. … Injury Prevention 2001;7:Supplement 38–42.

1107. Final Progress Report: Developing Best Practices for Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/2024-02/baker-report.pdf
      January 01, 2024 - delivery of hospital care.14 15 16 17 18 19 By some estimates, as many as a half million preventable injuries … preventable deaths may occur each year, at a cost estimated to exceed $30 billion per year.20 Most of these injuries … evidence on the effectiveness and cost of comprehensive patient safety programs for reducing avoidable injuries … Production pressure in the work environment: California anesthesiologists' attitudes and experiences … Production pressure in the work environment: California anesthesiologists' attitudes and experiences

1108. Fundamentals of Medicare Patient Safety Surveillance: Intent, Relevance, and Transparency (pdf file)
      www.ahrq.gov/downloads/pub/advances/vol2/Hunt.pdf
      July 01, 2004 - This urgency is, in part, precipitated by the confluence of market pressures to demonstrate value in … DVT/PE* Hospital acquired UTI** Ventilator associated pneumonia** Adverse drug events ** Pressure … care postoperative stays has shifted the diagnostic location for a large percentage of postoperative wound … reliable proxies for this event in the administrative claims, our ability to identify postoperative wound … A study of medical injury and medical malpractice: an overview.

1109. Fundamentals of Medicare Patient Safety Surveillance: Intent, Relevance, and Transparency (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Hunt.pdf
      July 01, 2004 - This urgency is, in part, precipitated by the confluence of market pressures to demonstrate value in … DVT/PE* Hospital acquired UTI** Ventilator associated pneumonia** Adverse drug events ** Pressure … care postoperative stays has shifted the diagnostic location for a large percentage of postoperative wound … reliable proxies for this event in the administrative claims, our ability to identify postoperative wound … A study of medical injury and medical malpractice: an overview.

1110. Final Progress Report: The Value of Hospital-Related Patient-Safety Interventions to Key Stakeholders (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/nuckols-report.pdf
      January 01, 2024 - Only half of basic care processes are provided as recommended, and injuries due to medical errors (preventable … electronic health records with computerized provider order entry (CPOE), which may reduce patient injuries … Conclusions: In hospital-related settings, implementing CPOE is associated with >50% decline in patient injuries … Cost Implications of Improving Blood Pressure Management among U.S. Adults.

1111. AHRQ Views: Celebrating the 40th Anniversary of the U.S. Preventive Services Task Force | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsletters/e-newsletter/920.html
      July 01, 2024 - 36 states from AHRQ’s Healthcare Cost and Utilization Project focusing on adverse outcomes such as pressure … Epidemiology and clinical outcomes of community-acquired acute kidney injury in the emergency department

1112. Archived: Obesity in Children and Adolescents: Screening | United States Preventive Services Taskforce
      www.uspreventiveservicestaskforce.org/uspstf/recommendation/obesity-in-children-and-adolescents-screening-2010
      January 15, 2010 - Adverse effects included elevated heart rate, elevated blood pressure, and adverse gastrointestinal effects … high-intensity comprehensive interventions. 15 However, decreases in cardiovascular risk factors (e.g., blood pressure … Other harms, such as risk of exercise-induced injuries, were considered minimal. … Adolescent sibutramine users were more likely to develop small increases in heart rate or blood pressure

1113. Duplicate Therapies in Retail Pharmacy | PSNet
      psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
      August 05, 2022 - 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?”

1114. Transitioning Newborns from NICU to Home: Family Information Packet, Appendix B (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb.pdf
      June 02, 2025 - ■ Should have: – Blood pressure checked at every visit. … are at risk for zinc deficiency and may need supplementation: – Poor growth, diarrhea, impaired wound … – Bivona ■ Cuffed: Indicated to prevent chronic aspiration, or when ventilating with high pressures … – Set suction pressure between 80-100 mmHg. … – Gastric or esophageal trauma during placement.

1115. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853080/psn-pdf
      August 30, 2023 - of Nursing Quality Indicators showed low incidence of catheter-associated urinary tract infections, pressure … injuries, deep vein thrombosis, and central-line associated blood stream infection.1 In terms of patient

1116. 018-Revision-Summary-Contact-Precautions (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/018-revision-summary-contact-precautions.docx
      October 01, 2024 - contact, changes in care that contribute to delays and non-infectious adverse events (e.g., falls, pressure … injuries), increased symptoms of depression and anxiety, and decreased patient satisfaction.16 · Adverse

1117. Getting the Diagnosis Both Right and Wrong | PSNet
      psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
      May 29, 2024 - 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

1118. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49677/psn-pdf
      February 01, 2013 - history of hypertension, psychiatric illness, and a previous suicide attempt overdosed on her blood pressure … The ED team thought this was likely due to severe hypotension (her systolic blood pressure was around … The possibilities for harm are numerous and include accidental trauma to non-venous structures (arteries … , lung, nerve, visceral organs); bleeding (hematoma, hemothorax, or hemorrhage); operator injury (needle … wire, bloodstream infections, sheared catheter, dysrhythmias, thrombosis, through-and-through vessel trauma

1119. Transition to Nowhere | PSNet
      psnet.ahrq.gov/web-mm/transition-nowhere
      March 21, 2009 - dystrophy, hypertension, and chronic kidney disease was admitted to the hospital with anuric acute kidney injury … transition management team could conduct a home visit or a telemedicine visit utilizing self-taken blood pressure … More Related Resources WebM&M Cases Under Pressure

1120. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49444/psn-pdf
      May 01, 2004 - Both doctors and nurses recounted professional requests for health care "favors" include taking blood pressures … In this case, the resident may not have been fully competent to perform the exam (resulting in injury … Additionally, failing to include nursing in procedures exposes patients to risks of injury related to