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1361. Timely Antibiotics for Children With Severe Sepsis or Septic Shock (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0230-fullreport.pdf
      April 02, 2018 - Unlike adults, the diagnosis of septic shock in children does not require the presence of low blood pressure … (hypotension), as children often maintain normal blood pressure until the advanced stages of shock … A limited window of opportunity exists for therapy of the underlying injury once shock is present. … Because children often maintain their blood pressure until they are severely ill, systemic hypotension … For severe sepsis, one abstractor indicated that there was a low systolic blood pressure despite the

1362. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/857059/psn-pdf
      November 29, 2023 - complications and the time period for ascertainment.11,14,17,18 The most common complications are wound … bumper” syndrome occurs in about 1-4% of cases6,9,14 when the PEG tube’s internal bumper causes focal pressure … Liver injury during PEG tube placement: report of two cases. … Trauma transitional care coordination: a mature system at work. … J Trauma Acute Care Surg. 2018;84(5):711-717. [Available at 48.

1363. In Conversation with...Joseph Britto, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-withjoseph-britto-md
      February 01, 2007 - And of course there is increasing pressure on the system to get it right, to not make so many mistakes … Yet the pressures in the market around pay for performance and transparency may conspire to begin stripping … Umpires make crucial split-second decisions under conditions of substantial pressure and uncertainty, … Rarely, the error may cause injury or death.

1364. Final Progress Report: Improved Patient Safety with Information Technology (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/overhage-report.pdf
      January 01, 2024 - The report estimated more than a million injuries and nearly 100,000 deaths attributable to medical … medication opportunities (not on an indicated med); (4) failed intermediate outcomes – e.g., high blood pressures … with CHF who are euvolemic (compensated) and on a low dose of an ACE inhibitor with systolic blood pressure … of 110, diastolic blood pressure of 80, and a heart rate of 76, adding a beta blocker is the next most

1365. Interpreting the Patient Safety Literature | PSNet
      psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
      June 01, 2005 - a particular patient safety intervention is going to save large numbers of lives or reduce serious injuries … intervention, they referred to any event that resulted in the emergency team being called—low blood pressure … the error caught by their regular physician, others would experience asymptomatic reduction in blood pressure

1366. Coming Undone: Failure of Closure Device | PSNet
      psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
      April 01, 2006 - The bleeding was not stopped by local pressure, and he returned to the hospital, where he was found to … July 10, 2019 Classifying errors in preventable and potentially preventable trauma deaths … WebM&M Cases Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury

1367. Virtual Patient Advocate to Reduce Ambulatory Adverse Drug Events (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r18hs017196-jack-final-report-2011.pdf
      January 01, 2011 - outcomes-assessors rated on an ordinal scale from 1-6 their confidence that medical management caused an injury … (injuries rated 5 or 6 are considered ADEs); (3) outcomes-assessors then rated each AE for ameliorability … the outcomes-assessors categorized the type of each ADE as: adverse drug event, procedure-related injury … For another patient, blood pressure was reviewed in detail, including recent lab test results and goals … (if alert rated as a potential problem or problem needing timely response) n=13: Procedure related injury

1368. A Patient Safety Program & Research Evaluation of U.S. Navy Pharmacy Refill Clinics (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Reige.pdf
      March 01, 2004 - an acute skeletal muscle relaxant medication for nearly a year; it was originally prescribed for injuries … Elderly people are at a higher risk for falls resulting in serious injury, and when a person is dizzy … When an elderly patient falls, serious injury may occur. … Part of the medication renewal process involves checking the patient’s blood pressure or performing

1369. 7.  Appendix C: Additional Tables by Topic Area | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/reports/2024-annual-report/appendix-c.html
      May 01, 2024 - Appendix D: Grant Summaries P1: Does A New Care Model Improve Care for Patients with Acute Kidney Injury … program that supports patients discharged from the hospital to home after an episode of acute kidney injury … Prioritizing Quality Improvement for the Treatment of Psychiatric Disturbances Following Traumatic Brain Injury … support in rural primary care practices to provide evidence-based clinical care recommendations for blood pressure … practice facilitation would improve the use of a hypertension-focused CDS to effectively improve blood pressure

1370. Testdatajson
      cds.ahrq.gov/sites/default/files/cds/artifact/106/testDataJSON.txt
      December 12, 2014 - Comorbidities_comorbidity_jointpain\",\"data\":\"Review\",\"internal\":\"Hip pain - Yes\\nKnee pain - Yes\\nLimp - Yes\\nTrauma or injury … delimrtf D" , "iagnoses:\\par \\tab BMI 85th-95th percentile\\par \\tab Diabetes\\par \\tab Elevated Blood Pressure … Flowsheet" , "unit" : "CM" , "value" : "137.16" } , { "contactid" : "58119.99" , "datatype" : "BLOOD PRESSURE … "Flowsheet" , "unit" : "CM" , "value" : "132.08" } , { "contactid" : "57998" , "datatype" : "BLOOD PRESSURE

1371. AHRQ Transforming Primary Care Grants | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/research-transform-primary-care/transform/tpcbib/index.html
      May 01, 2015 - Hemoglobin A1c and blood pressure values in patients with diabetes were not significantly different between … The number of hospitalizations for unintentional injury and asthma also decreased after implementation … PMID: 23690385 The authors compared emergency care usage for any reason, asthma, and unintentional injury … As a comparison, emergency care use for unintentional injury had been increasing before and during implementation … Among patients with hypertension, frequent in-person visits were associated with better blood pressure

1372. Final Progress Report: Making Acute Care More Patient Centered, Patient Safety Learning Laboratory (PSLL) (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/bates3-report.pdf
      January 01, 2024 - concordance by patients and care team members, and the incidence of patient falls and fall-related injuries … The effect of the intervention on patient falls (dichotomized as fall/no fall) and falls with injury … (dichotomized as falls with injury/no injury) was analyzed using logistic regression estimated via … Scope Inpatient adverse events (AEs) are patient injuries due to medical management that prolong hospitalization … Bowel Regimen, Venous Thromboembolism (VTE) Prophylaxis, Opioid Management, Antibiotic Management, Pressure

1373. Findings and Lessons From the Enabling Quality Measurement Through Health IT Grant Initiative (pdf file)
      digital.ahrq.gov/sites/default/files/docs/page/final-eqm-report-6-21-12.pdf
      May 01, 2012 - and modeling to iden- This is one in a series of five reports highlighting tify preventable patient injuries … The grantees confirmed that higher scores on the disease management indices for blood pressure were … data from the EHR, that the latter ap- proach was highly accurate for case identification for blood pressure … mix adjustment model to account for patient heterogeneity, comparing actual hemoglobin A1c, blood pressure … had a modest impact on treatment intensification rates for patients with elevated systolic blood pressure

1374. AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety.pptx
      May 01, 2017 - fetal criteria for procedures that increase risk for cord prolapse47 such as— amniotomy intrauterine pressure … Effects of shoulder dystocia training on the incidence of brachial plexus injury. … Shoulder dystocia and injuries: prevention and management.

1375. Lost in Sign Out and Documentation | PSNet
      psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
      January 31, 2011 - coronary care unit (CCU) with respiratory failure requiring mechanical ventilation and acute kidney injury … More Related Resources WebM&M Cases Under Pressure

1376. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33645/psn-pdf
      February 01, 2007 - Umpires make crucial split-second decisions under conditions of substantial pressure and uncertainty … Rarely, the error may cause injury or death.

1377. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49419/psn-pdf
      October 01, 2003 - is increased when multiple procedures are performed on the same patient, when a team is under time pressure … Error disclosure for patients, however, is merely the first step in a long process of adjustment to an injury

1378. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-471
      December 31, 2024 - On arrival at the emergency department, she had severely elevated blood pressure and hypoxemia. … continuing challenge of preventing falls and explores strategies for preventing falls and falls with injury

1379. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/handouts.html
      September 01, 2017 - Report data help identify residents with new ADL decline, fall risk, or fall injury, therefore at risk … and Rehab  Managers Weekly huddle to review residents at risk for ADL decline or fall or with fall injury … with stage 2 or above pressure ulcers at risk for infection who potentially require hospitalization/ … Reports provide information about current and changing risks for pressure ulcer healing and can aid root … Discharge diagnoses were dehydration, fall with injury, cellulitis, and angina.

1380. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72516/psn-pdf
      November 25, 2020 - 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 … ST-segment abnormalities in a patient with a recent history of head trauma and no chest pain should … “Has this patient suffered recent head trauma or is this patient at increased risk of head trauma?”)