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1281. Final Progress Report: Evaluating the Impact of Simulated Team Training on Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/scott-report.pdf
      January 01, 2024 - Use the ambulatory surgical setting as a model to better understand risks and injuries and to focus … University of Michigan, complications may occur in nearly 13% of cases.4 Preventable healthcare-related injuries … Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization … by the team; and 3) Hypercarbia – the patient becomes hypercarbic with increased peak inspiratory pressures … and implement team training curricula regarding other domains, such as rare event crises in the OR, trauma

1282. Electronic Medication Adherence Reporting and Feedback During Care Transitions - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r21hs024587-schnipper-final-report-2019.pdf
      January 01, 2019 - Several studies have shown that post-discharge adverse drug events (ADEs, injury due to a medication … evaluated in the transitions setting, where there are unique logistical challenges, e.g., due to time pressures … of disease control (Table 4a and 4b), those assigned to the smart pillbox overall had better blood pressure … control, especially diastolic blood pressure (arguably the more important of the two measures) in fully … goal of < 130 mmHg or decrease to that goal if not at goal at baseline b Maintain diastolic blood pressure

1283. Disposition of Comments Report for Comparative Effectiveness Review #68 (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/nppv-respiratory-failure_disposition-comments.pdf
      July 01, 2012 - Noninvasive Positive–Pressure Ventilation (NPPV) for Acute Respiratory Failure. … When expiratory pressure is combined with higher inspiratory pressure in bilevel modes, it is not continuous … There are in fact two pressures: a continuous level that is periodically augmented by additional inspiratory … pressure. … Role of noninvasive ventilation in acute lung injury/acute respiratory distress syndrome: a proportion

1284. Research | Digital Healthcare Research
      digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/research
      January 01, 2023 - Hicks LS et al. 2008 "Impact of computerized decision support on blood pressure management and control … McDowell I et al. 1989 "A randomized trial of computerized reminders for blood-pressure screening in … …compares "three ways of encouraging patients in a large family practice to obtain a blood pressure check … Soopramanien A et al. 2005 "Using telemedicine to provide post-discharge support for patients with spinal cord injuries … discharge to provide participants with regular telemedicine sessions conducted by specialists in spinal injury

1285. Diabetes-Behavior-Programs Research-Protocol (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/diabetes-behavior-programs_research-protocol.pdf
      June 05, 2014 - Question 4 For patients with T1DM, what are the associated harms (i.e., activity-related injury) of … by participant attrition rates • Harms from program as reported for studies - Activity-related injury … Harms related to the intervention (i.e., activity-related injury) may occur at any point during the … Source: www.effectivehealthcare.ahrq.gov Published online: June 5, 2014 9 Harms • Activity- related injury … Tight blood pressure control and risk of macrovascular and microvascular complications in Type 2 diabetes

1286. Disposition of Comments for Management of Suspected Opioid Overdose With Naloxone by Emergency Medical Services Personnel (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-193-disposition-comments-naloxone.pdf
      November 27, 2017 - line 22: There is some evidence that even trained EMS providers often provide substandard positive pressure … We also added the sentence: “In addition, negative pressure ventilation (i.e., patients breathing … on their own) is more likely to achieve adequate oxygenation than manual positive pressure ventilation … Also, the risk of adverse event will also have to do w/ the pt's overall health otherwise (wound infxns … The IN method takes the needle out of the equation- -which reduces needle-stick injuries, and in PWID

1287. Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To? | PSNet
      psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tissue-infection-who-does-patient-belong
      March 31, 2021 - when) treated in a timely and aggressive manner. 1 Rarely, NSTIs can occur as a severe postoperative wound … If he or she described a ‘wound infection in a plastic surgery patient,’ for example, this would have … Burnout Physician burnout (also referred to as “moral injury”) is an ongoing topic of discussion in medicine … survey of subspecialty surgeons: “while EGS surgeons appear to meet [a clinical] need and relieve some pressure … Journal of Trauma and Acute Care Surgery . 2018 July;85(1):208-214.

1288. Cervical Ripening in the Outpatient Setting (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/ocr-protocol-final_1.pdf
      December 18, 2019 - (e.g., bone fracture, neurologic injury, or retinal hemorrhage)c • Intracranial or subgaleal … (e.g., bone fracture, neurologic injury, or retinal hemorrhage)c • Intracranial or subgaleal … (e.g., bone fracture, neurologic injury, or retinal hemorrhage)c • Intracranial or subgaleal … (e.g., bone fracture, neurologic injury, or retinal hemorrhage)c • Intracranial or subgaleal … maternal age, gestational age, race and ethnicity), pregnancy risk factors (such as diabetes, high blood pressure

1289. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49726/psn-pdf
      March 01, 2015 - as a sentinel event—an unexpected occurrence involving death or serious physical or psychological injuries … markings, surgeon fatigue, numerous surgeons, multiple procedures on the same patient, atypical time pressures

1290. Wheeled Mobility (Wheelchair) Service Delivery (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/wheelchair-service_disposition-comments.pdf
      January 01, 2012 - or trauma. … or trauma. … living (ADLs), instrumental activities of daily living (IADLs), functional mobility, positioning, pressure … living (ADLs), instrumental activities of daily living (IADLs), functional mobility, positioning, pressure … And in many cases this care (e.g. wound care) cannot be provided by a therapist or supplier.

1291. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49550/psn-pdf
      December 01, 2007 - preoperative period but suffered a pulseless electrical activity arrest in the operating room at the time of wound … based on 1997 data from the National Inpatient Sample Excludes patients with any code for cancer, trauma … Excludes patients with any diagnosis code for drug dependence, abuse of drugs, or self-inflicted injury … Decubitus ulcer Pressure sores in patients hospitalized for 4 days or longer Discharges with ICD … diagnosis among all surgical discharges Excludes patients who have principal diagnosis codes for trauma

1292. References | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-pediatric-safety-refs.html
      August 01, 2023 - Identification of children at very low risk of clinically-important brain injuries after head trauma: … Physicians' Risk Tolerance and Head Computed Tomography Use for Pediatric Patients With Minor Head Injury … Cluster Randomized Trial Reducing Missed Elevated Blood Pressure in Pediatric Primary Care: Project RedDE … Disparities in the evaluation and diagnosis of abuse among infants with traumatic brain injury. … The use of telemedicine in the care of the pediatric trauma patient. Semin Pediatr Surg .

1293. Urine Culturing Stewardship in the ICU Setting Facilitator Notes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urine-culturing-notes.docx
      April 01, 2022 - Her temperature is 100.8 degrees Fahrenheit, heart rate 130, respiratory rate 22, and blood pressure … mistakenly considered an unavoidable “cost of doing business” instead of understood as avoidable, tragic injury

1294. Dietary-Supplements Surveillance (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/dietary-supplements_surveillance.pdf
      January 01, 2013 - were not significant (results for lipids and blood pressure inconclusive; grade: insufficient). … The Effects of n-3 Long-Chain Polyunsaturated Fatty Acid Supplementation on Biomarkers of Kidney Injury … diuretics, 81% on meds for Type II DM Mixture of omega-3 FA 3g/d Corn oil Markers of kidney injury … C-reactive Protein; HTN hypertension; hx history; INR international normalized ratio; KIM-1 Kidney Injury … were not significant (results for lipids and blood pressure inconclusive; grade: insufficient).

1295. Final Progress Report: Individualized Performance Feedback on Venous Thromboembolism Prevention Practice (pdf file)
      www.ahrq.gov/sites/default/files/2025-06/haut-report.pdf
      January 01, 2025 - handwashing, VTE prevention, medication prescribing, diagnostic imaging, medication reconciliation, pressure … injury prevention, antibiotic use, discharge summary, and laboratory testing. … Receive feedback Want feedback Patient nutrition Medication reconciliation Handwashing Pressure … injury prevention VTE Prevention Antibiotic use Medication prescribing Discharge summary

1296. Archived: Evidence Summary: Obesity in Children and Adolescents: Screening | United States Preventive Services Taskforce
      www.uspreventiveservicestaskforce.org/uspstf/document/evidence-summary/obesity-in-children-and-adolescents-screening-june-2017
      June 20, 2017 - and −4.0 mm Hg (95% CI, −5.6 to −2.5; 6 studies; I 2 = 17%) for diastolic blood pressure. … treatment (eg, labeling, stigma or increased body image concerns, eating disorder, exercise-induced injury … (systolic blood pressure [SBP] pooled mean difference in change between groups, −6.4 mm Hg [95% CI, … None of the trials reporting lipid or blood pressure outcomes showed a benefit with metformin. … Blood pressure in obese and overweight children and adolescents.

1297. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50614/psn-pdf
      October 30, 2019 - lines, you don't have to go anywhere near the great vessels of the neck or the chest, so you avoid injury … You avoid injury to the lung—that dreaded complication of pneumothorax. … You just put pressure at that site in the arm and compress the vessel against the underlying humerus … Think about it: when you insert a PICC, your needle causes endothelial injury, in a patient that's hypercoaguable

1298. Intravenous Infusion Safety Initiative: Collaboration, Evidence-Based Best Practices, and “Smart” Technology Help Avert High-Risk Adverse Drug Events and Improve Patient Outcomes (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Maddox_38.pdf
      March 26, 2008 - leading cause of patient harm is medication errors, which account for almost 20 percent of medical injuries … .1 Twenty-eight percent of medication-related injuries (adverse drug events, ADEs) are considered preventable … Anesthesia Patient Safety Foundation (APSF) notes a significant, underappreciated risk of serious injury … with other medication errors, IV infusion programming errors have a greater likelihood of causing injury … programmed, appropriate doses of opiates can suppress respiration and decrease heart rate and blood pressure

1299. Final Progress Report: A National Report of Nursing Home Quality Measures and Information Technology (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/alexander-report.pdf
      January 01, 2024 - daily living has increased; 2) who have moderate to severe pain; 3) who are at high risk and have pressure … sores; 4) who are at low risk and who have pressure sores; 5) who are physically restrained; 6) who … the percentage of residents 1) with delirium; 2) who have moderate to severe pain; 3) and who have pressure … Symptoms 14168 797 5.6 5.1 Who Were Physically Restrained 14203 798 0.9 0.7 One or More Falls with Major Injury … Physically Restrained -0.02 -0.02 0.01 0.01 0.01 0.01 0.01 0.00 -0.02 0.00 One or More Falls with Major Injury

1300. Behavioral Counseling Research and Evidence-Based Practice Recommendations: U.S. Preventive Services Task Force Perspectives | United States Preventive Services Taskforce
      www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/behavioral-counseling-research-and-evidence-based-practice-recommendations-us-preventive-services-task-force-perspectives
      March 01, 2014 - example, from alcohol misuse to illicit substance use or from weight control to disordered eating) or injuries … recent meta-analysis of physical activity trials reported an increase in risk factors (such as blood pressure … Even the assessment of intermediate biometric risk factors, such as lipid level, blood pressure, and … Further, national longitudinal studies that include biometric assessments, such as blood pressure, blood