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1421. CER 220: Disposition of Comments Report for Comparative Effectiveness of Analgesics To Reduce Acute Pain in the Prehospital Setting (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-220-disposition-comments-analgesics-prehospital-setting.pdf
      September 03, 2019 - What about other direct injury? … is not a fair substitute for prehospital care – patients would necessarily have the same extent of injury … Many of the opioid studies were pre hospital battlefield injuries. … We have added a statement that patients with multiple major traumas, crushed pelvis or major burns … Page 62 Line 18: Change “less” to “lower” oxygen saturation and “more” to “higher” systolic blood pressure

1422. In Conversation With... Freya Spielberg, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
      September 28, 2022 - A big step was just educating people that, in fact, they have high blood pressure and how they can take … As part of this education, the community health worker would give a patient a blood pressure monitor … so they could take their own blood pressure at different times during the day and see for themselves … that since hypertension is such a huge issue in these populations, everybody should have a home blood pressure … AHRQ’s broad definition of patient safety includes “prevention of diagnostic errors, medical errors, injury

1423. Final Progress Report: Human Factors and Systems Integration in High Technology Surgery (HF-SIgHTS) (pdf file)
      www.ahrq.gov/sites/default/files/2025-07/catchpole-report.pdf
      January 01, 2025 - model of the mechanisms by which small seemingly innocuous events escalate to create serious surgical injuries … verbal communication which is already the most frequently cited cause of procedural error and surgical injury … separation among members of the OR team, new anesthesia strategies, coordination and communication pressures … verbal communication which is already the most frequently cited cause of procedural error and surgical injury … primarily applied in surgery, comparable research has been successfully conducted in other venues such as trauma

1424. Glaucoma-Screening Executive (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/glaucoma-screening_executive.pdf
      April 01, 2012 - glaucoma may be characterized by optic nerve damage, visual field loss, and elevated intraocular pressure … The USPSTF noted that intraocular pressure measurement and optic nerve head assessment alone have limited … KQ4b: How does intraocular pressure vary when comparing different screening-based programs for open- … Goldmann Applanation Tonometry (GAT) Tonometry is the measurement of intraocular pressure (IOP). … Detection of psychophysical and structural injury in eyes with glaucomatous optic neuropathy and normal

1425. Urine Culturing Stewardship in the ICU Setting Facilitator Notes
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urine-culturing.pptx
      April 01, 2022 - Abbreviations: BP = blood pressure; GI = gastrointestinal; Hgb = hemoglobin; HR = heart rate; ICU = intensive … without evidence of another source on history, physical examination, or laboratory testing In spinal cord injury … Has the patient had recent urologic manipulation such as trauma to the GU tract or surgery? … Effectiveness of a bundled approach to reduce urinary catheters and infection rates in trauma patients

1426. Archived: Final Evidence Summary: Carotid Artery Stenosis: Screening, December 2007 | United States Preventive Services Taskforce
      www.uspreventiveservicestaskforce.org/uspstf/document/final-evidence-summary11/carotid-artery-stenosis-screening-december-2007
      December 15, 2007 - Although it is difficult to determine the intensity of medical management, the mean systolic blood pressure … However, among the RCTs, the VACS reported a surgical complications rate of 3.8% for cranial nerve injuries … (none of these injuries were permanent), 5.2% for hypotension, and 25% for hypertension. 34 Return … Cumulative effects of high cholesterol levels, high blood pressure, and cigarette smoking on carotid … Overall=3.7% High volume hospital (>100 cases/year) = 3.5% Low volume hospital=5.2% 3% HTN 2% wound

1427. Creating a Culture of Patient Safety through Innovative Hospital Design (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
      January 01, 2004 - Unfortunately, a small portion of errors do result in an “adverse event”—an injury caused by medical … For example, a 1991 Harvard Medical Practice Study reported that 69 percent of injuries suffered by … hospitalized patients in New York State in 1984 were the result of errors, and nearly 14 percent of these injuries … It may elevate blood pressure, increase pain, alter quality of sleep, and reduce overall perceived

1428. An Incomplete Anesthesia History Leads to Adverse Outcomes | PSNet
      psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
      January 29, 2021 - The trauma team was called to assist and the patient was given additional sedation and opioid analgesia … The trauma surgeon then manipulated both TMJs and was finally able to unloose the locked jaw. … diagnosis and a physician experienced in reducing the TMJ should be consulted to minimize the risk of injury … Placing staff under too much time pressure can, at times, be counterproductive and can adversely affect

1429. Ratio of Magnetic Resonance Imaging Scans to Computed Tomography Scans for the Evaluation of Children with Atraumatic Seizure: Report (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0197-fullreport.pdf
      November 01, 2019 - These complications include compromised airway, hypoxia leading to central nervous system injury, and … moderate and deep sedation carry risk of airway compromise, hypoxia resulting in central nervous system injury … These risks include dental trauma; airway edema (swelling of the windpipe); vocal cord spasm or injury … ; regurgitation of stomach contents with subsequent aspiration (inhalation) pneumonia; injury to arteries … , veins, or nerves; alterations in blood pressure; and/or irregular heart rhythms (Society for Pediatric

1430. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy | PSNet
      psnet.ahrq.gov/web-mm/risks-absent-interoperability-medication-induced-hemolysis-patient-known-allergy
      April 08, 2019 - The Case A 47-year-old man with paraplegia (secondary to a gunshot wound) and a history of polysubstance … Unfortunately, his cardiac arrest led to an anoxic brain injury, and he remained in a vegetative state … 11  Laboratory test(s) 12  Laboratory value(s)/result(s) 13  Vital signs: height, weight, blood pressure

1431. Final Progress Report: Creating Safe Ambulatory Care: The Path to Resilience (pdf file)
      www.ahrq.gov/sites/default/files/2025-04/nemeth-report.pdf
      January 01, 2025 - exploratory study of ambulatory care settings was to identify and minimize or eliminate the potential for injuries … Time pressure can force clinicians to make decisions on insufficient or ambiguous information. … Patients who report shortness of breath (suggesting cardiac or pulmonary crises) or have suffered trauma

1432. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
      January 01, 2024 - 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

1433. Signout Fallout | PSNet
      psnet.ahrq.gov/web-mm/signout-fallout
      November 16, 2022 - sentinel events—defined as "an unexpected occurrence involving death or serious physical or psychological injury … Post-Tracheostomy Care May 29, 2024 WebM&M Cases Under Pressure

1434. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49855/psn-pdf
      March 01, 2019 - harmed by having the incorrect catheter placed, but the error was eventually discovered and further injury … The efficacy of self- check is limited by time pressure and by asymmetric knowledge—individuals in the

1435. Statistical Brief #77: Payers of Emergency Department Care, 2006 (pdf file)
      hcup-us.ahrq.gov/reports/statbriefs/sb77.pdf
      July 01, 2009 - by law1 to receive a medical screening exam to determine if they need treatment for an illness or injury … who is paying for ED care, what the charges are for the care, and how to potentially relieve this pressure

1436. Webinar Transcript - The National Quality Strategy and the Public Sector: Federal Agency Alignment to the Six Priorities | Agency for Healthcare Research and Quality
      www.ahrq.gov/workingforquality/events/webinar-federal-agency-alignment-to-the-six-priorities.html
      November 01, 2016 - We work to prevent the leading cause of illness, injury, disability, and death. … We've displayed performance on the ABCs, which are appropriate aspirin use, blood pressure control, control … tobacco and got preventive care, we still have to address modifiable risk factors, including blood pressure … their profit according to the extent to which they're able to assist their members in controlling blood pressure

1437. Functional Assessment Screening Patient Reported Information: FAST-PRI - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r18hs018932-hess-final-report-2015.pdf
      January 01, 2015 - care organizations…should adopt as their explicit purpose to continually reduce the burden of illness, injury … you less likely to have medical problems such as: Diabetes Heart disease Colon Cancer High blood pressure … less likely to have medical problems such as: Diabetes Heart disease Colon Cancer High blood pressure … you less likely to have medical problems such as: Diabetes Heart disease Colon Cancer High blood pressure

1438. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61083/psn-pdf
      October 28, 2020 - In putting all of this in place, did you see reductions in harms like pressure injuries, resident falls

1439. Prescribers-Facilitator-Guide (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/prescribers-facilitator-guide.docx
      June 01, 2021 - unanticipated event in a health care setting resulting in death or serious physical or psychological injury … Half of the respondents in that study reported feeling pressure to give a medication for which they questioned

1440. Patient Safety Organizations: A Summary of 2014 Profiles (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-portfolios-summary-profile-2014.pdf
      January 01, 2014 - The term safety refers to reducing risk from harm and injury, whereas the term quality suggests striving … Information Form, and Summary of Initial Report Form) and then applying Common Formats for falls, pressure