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1181. Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement | PSNet
      psnet.ahrq.gov/perspective/zero-harm-striving-reduce-preventable-harms-point-counterpoint-and-areas-agreement
      September 24, 2024 - safety culture and found a 37% increase in reporting, and decreases in preventable harm: 39% decrease in injuries … with falls, 37% fewer pressure injuries and a 34% reduction in central line-associated blood stream … For instance, a hospital may focus on eliminating severe pressure injuries as a preventable harm, but … Carole Stockmeier:  Patients come to us with faith, hope, and trust that we will restore health and heal wounds

1182. Screening Children for Family Violence: A Review of the Evidence (pdf file)
      www.uspreventiveservicestaskforce.org/home/getfilebytoken/qCaKmh7ayuG9VP2vj646pQ
      March 01, 2004 - These problems include acute trauma, including death, unwanted pregnancy, and long-term physical and … , injury histories inconsistent with physical findings, and injuries inconsistent with children’s abilities … We excluded studies about patients presenting with trauma. … *Including physical trauma (fractures, dislocations, brain injury, etc.); unwanted pregnancy and sexually … 71% of respondents rated the identification of maltreatment as rather difficult or difficult.70 Work pressure

1183. Archived: Evidence Summary: Child Maltreatment: Counseling, 2004 | United States Preventive Services Taskforce
      www.uspreventiveservicestaskforce.org/uspstf/document/evidence-summary/child-maltreatment-counseling-2004
      March 09, 2004 - These problems include acute trauma, including death, unwanted pregnancy, and long-term physical and … , injury histories inconsistent with physical findings, and injuries inconsistent with children's abilities … We excluded studies about patients presenting with trauma. … of respondents rated the identification of maltreatment as rather difficult or difficult. 70 Work pressure … *Including physical trauma (fractures, dislocations, brain injury, etc.); unwanted pregnancy and sexually

1184. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department. | PSNet
      psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
      January 23, 2017 - transferred by ambulance to a tertiary Emergency Department (ED) from a referring hospital due to a left leg injury … holding her left hip flexed with significant tenderness on examination, but there were no other signs of trauma … during a diagnostic or therapeutic procedure.” 4,5 Sedation can also ameliorate the psychological trauma … exist when sedation is urgently needed to prevent harm associated with the underlying condition or injury … Blood pressure should be measured frequently, and the electrocardiogram, heart rate, respiratory rate

1185. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60066/psn-pdf
      March 25, 2020 - Her vital signs included: blood pressure 154/113 mmHg, heart rate 75 beats/minute, respiratory rate … 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 … patients, who require direct supervision, triages them ahead of many complicated, sick medical and trauma … Multidisciplinary Simulation-Based Team Training for Trauma Resuscitation: A Scoping Review.

1186. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865984/psn-pdf
      May 29, 2024 - Angina is typically described as a pressure-like or squeezing sensation in the chest, associated with … remember that electrocardiographic changes are not seen in unstable angina, as there is no permanent injury … limit Table adapted from Long et al. (2017)9 1Examples of risk factors include retrosternal pain, pressure

1187. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49654/psn-pdf
      June 01, 2012 - They had taken her to the operating room, but she developed low blood pressure before the case and the … An evaluation of compliance with practice guidelines on interhospital trauma transfer. … Injury. 2005;36:1051-1057. [go to PubMed] 15. … Injury. 2004;35:857-863. [go to PubMed] 17. Lee A, Lum ME, Beehan SJ, Hillman KM.

1188. Improving Patient Safety in Long-Term Care Facilities: Training Modules (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/ltcinstructor.pdf
      June 01, 2012 - safety, create a more resident-centered environment, and reduce the number of falls and fall-related injuries … In addition, they should be able to manage injuries that result from falls. … Risk factors are identified, and ways to prevent injury are discussed. … Paul comes to visit his father after work; he is aware that his father fell yesterday, without injury … use to reduce the number of falls. › Nursing staff must have the knowledge and skills to prevent injury

1189. Making Healthcare Safer IV Rapid Response: Acute Care Nursing Staff Shortages That Compromise Patient-to-Nurse Ratios (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/nursing-staff-shortages-rapid-research.pdf
      April 01, 2025 - injuries, catheter-associated urinary tract infections, surgical site infections, and sepsis cases … The emergency department was restructured to cohort patients by specialty (e.g., trauma, pediatrics … The emergency department was restructured to cohort patients by specialty (e.g., trauma, pediatrics) … pandemic, and which sought to re-organize work structures to enhance nurses’ ability to cope with these pressures … California's nurse-to-patient ratio law and occupational injury.

1190. Pharmacologic Management of Acute Pain by EMS in the Prehospital Setting Protocol Amendment (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/acute-pain-ems-protocol-amendment.pdf
      January 28, 2019 - medical conditions or patient characteristics (e.g., dental pain, abdominal pain, depressed blood pressure … Prehospital trauma analgesia. J Emerg Med. 2008;35:47-57. 3. … An evidence-based guideline for prehospital analgesia in trauma. … Continuous infusion of ketamine for out-of-hospital isolated orthopedic injuries secondary to trauma … Adding the following outcomes to KQ 2 and 4: systolic blood pressure, diastolic blood pressure,

1191. Final Progress Report: Implementing Reduced Work Hours for All House Staff To Improve Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/2024-02/landrigan2-report.pdf
      January 01, 2024 - begin their work day 8-10 hours after awakening (86), leaving them with more accumulated homeostatic pressure … (i.e., injuries from needle sticks and scalpel laceration), and ‘fall-asleep’ incidents. … extended-duration shifts compared to non-extended-duration shifts. (99) In addition, the odds of a needlestick injury … A computer alert system to prevent injury from adverse drug events. JAMA 1998;280(1317):1320. … Extended work duration and the risk of self-reported percutaneous injuries in interns.

1192. Implement-Facilitator-Guide (doc file)
      www.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

1193. Identifying, Understanding, and Communicating Medical Device Use Errors: Observations from an FDA Pilot Program (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flack.pdf
      January 01, 2005 - 519, mandates that all manufacturers of medical devices must report device-related deaths, serious injuries … facilities” must report medical device related deaths to FDA and to the manufacturer and report serious injuries … of medical devices so it could become more proactive in addressing device issues before a death or injury … the various types and sizes of facilities that are obligated to make reports of deaths and serious injuries … systems are really at the root of the problem, and c) clinicians report they are just too busy with the pressures

1194. Final Progress Report: Incident Reporting Practices in Nursing Homes (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/castle-report.pdf
      January 01, 2025 - states, however; for example, abuse incidents are taken very seriously, but falls, other incidents, and pressure … events or medication errors; resident altercations or other types of abuse; and non-fall related injuries … Compared to 38.5% surveyor visits for burns and 22.7% for pressure ulcers, the numbers are fairly low … The relationship between physical restraint removal and falls and injuries among nursing home residents … ., dispensing, administration, adverse drug event) 27 17.3 6.3 69.3 7.1 24 12.5 4.2 66.7 16.7 Pressure

1195. Final Progress Report: Demonstration Project To Refine, Automate and Test a Novel Emergency Department Trigger Tool (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/griffey-report.pdf
      January 01, 2025 - preventable.6-9 Numerous factors, such as increasing acuity, limited data for decision making, time pressures … We queried home medications, chief complaint, triage data such as acuity and trauma leveling, keywords … BiPAP – bilevel positive airway pressure; CPAP – continuous positive airway pressure; D50 – 50% Dextrose … (11%), and pressure ulcers (12.3%). … hypoxia and hypotension, delirium/ confusion, various bleeding events, surgical complications and injuries

1196. Evidence-based Practice Center Systematic Review Protocol (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/disabilities-quality-improvement-outcomes_research-protocol.pdf
      August 03, 2011 - can also be differentiated by etiology: developmental disabilities, disabilities acquired through trauma … Preventive Services Task Force) o Urinary tract infections o Pressure ulcers o Uncontrolled diabetes … functioning and disability… as a dynamic interaction between health conditions (diseases, disorders, injuries … , trauma, etc.) and contextual; factors, including the social, attitudinal, and physical environments … . intellectual disabilit$.mp. 3092 9. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 214730 10. exp Pressure

1197. Appendix VII: Public Comments Submitted Between March 7 and March 21, 2008 (continued) | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apviia.html
      June 01, 2010 - of State Directors of Developmental Disabilities Services, the National Associations of State Brain Injury … agencies, units on aging, agencies serving individuals with physical disabilities, traumatic brain injury … Medicaid-eligible individuals who are frail and elderly, have intellectual and developmental disabilities, head injuries … of State Directors of Developmental Disabilities Services, the National Associations of State Brain Injury … future and the "Never Events," I did not see any use of the never events, including: Stage 3 or 4 pressure

1198. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49662/psn-pdf
      August 01, 2012 - insertion site, hemorrhage, peritonitis, buried bumper syndrome, gastrocolocutaneous fistula, small bowel injury … involves avoiding tight traction on the PEG tube as this practice may increase ischemia and delay wound … healing.(3) All dressing changes should incorporate a careful wound inspection for redness or leakage … Parkinson disease, central nervous system tumor, amyotrophic lateral sclerosis, cerebral palsy • Severe trauma … Invaginate gastric wall, visible from endoscope with external digital pressure 4.

1199. Premature Closure: Was It Just Syncope? | PSNet
      psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
      February 10, 2021 - His initial vital signs in the ED were notable for a systolic blood pressure in the 100s and a heart … This suggests that the clinicians initially considered trauma but prematurely narrowed their focus to … additional history-taking may have revealed the patient’s recent history of falls with repeated closed head injuries … “Has this patient suffered recent head trauma or is this patient at increased risk of head trauma?”) … June 14, 2023 WebM&M Cases Under Pressure: Delayed

1200. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. | PSNet
      psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-complications-after-gastric-bypass-surgery
      September 25, 2019 - Due to the delayed diagnosis, the patient suffered permanent brain injury requiring around-the-clock … These barriers include professional hierarchy, time pressure, challenging workloads, and inadequate structures … Post-Tracheostomy Care May 29, 2024 WebM&M Cases Under Pressure … Infusion July 31, 2023 WebM&M Cases Under Pressure