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1441. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49624/psn-pdf
      May 01, 2011 - ICU, he was noted to have fixed and dilated pupils on neurologic exam, a sign of serious neurologic injury … Strong psychological pressures accompanying these events (not wanting to admit a mistake) can bias the

1442. Final Progress Report: Pursuing Perfection in Pediatric Therapeutics (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/lannon2-report.pdf
      January 01, 2024 - Predict and prevent nephrotoxic medication-associated acute kidney injury in noncritically ill hospitalized … Electronic Health Record Identification of Nephrotoxin Exposure and Associated Acute Kidney Injury. … -55 27803957 2017 NPC-QIC Improvement/outcomes Frank G, Walsh KE, Wooton S, et al Impact of a Pressure … Injury Prevention Bundle in the Solutions for Patient Safety Network Pediatric quality & safety

1443. Health IT Hazard Manager Beta-Test (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/HealthITHazardManagerFinalReport.pdf
      May 01, 2012 - note, the focus of most reporting systems on analyzing adverse events “means that injury has already … note, however, “Most reporting systems concentrate on analyzing adverse events; this means that injury … should establish a mechanism for both vendors and users to report health IT-related deaths, serious injuries … Intracranial Pressure Calculation: The formula for calculating intracranial pressure (ICP) was re-entered … incorrectly by local IT staff as part of a software upgrade, with the result that all pressures were

1444. Chartbook on Women's Health Care: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/womenhealth/womenh-slides.html
      March 01, 2020 - Importance: About 70 million American adults (29%) have high blood pressure ( Nwankwo, et al., 2013 … High blood pressure costs the Nation $46 billion each year. … mostly attributable to sudden unexpected infant death (SUID), congenital anomalies, infection, and injury … Web-based Injury Statistics Query and Reporting System (WISQARS) [Online] (2013). … http://www.cdc.gov/injury/wisqars/index.html . Accessed September 1, 2015.

1445. Chartbook on Effective Treatment: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/nhqrdr/chartbooks/effectivetreatment/effectivetreatment-slides.html
      April 01, 2018 - Most Costly Conditions, 2013 Condition Total Expenses (Millions) Report Section Trauma-related … Blood pressure under control is defined as having a mean systolic blood pressure <140 and mean diastolic … blood pressure <90 among all hypertensive patients. … , blood pressure control among people with diagnosed high blood pressure remains a problem. … Increased risk of death from car crashes and other injuries.

1446. Learning from Errors in Ambulatory Pediatrics (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Mohr.pdf
      February 01, 2004 - Because of the age of pediatric patients, when an error leads to injury it may have an impact on the … No complete loss of consciousness -- mom caught him with no head injury sustained. … post-term newborn infant with mild respiratory distress syndrome requiring continuous positive airway pressure … The occurrence of an error did not imply harm or injury to the patient.

1447. Meeting Minutes, November 2017 | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/events/nac/2017-11-nac/nacmtg1117-minutes.html
      February 01, 2018 - Preliminary data on the use of the training materials showed significant decreases in falls with injury … AHRQ also released training materials for preventing pressure ulcers in hospitals. … Preliminary data on use of the materials showed significant decreases in pressure ulcers during a 1-year

1448. Slide 1 (ppt file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/preventing-cauti-engaging-clinicians-051413.ppt
      January 01, 2013 - Reduce antibiotic use Reduce potential of increased resistance and Clostridium difficile disease Reduce trauma … (mechanical complications): Metal and urethral injury Hematuria Hospitalists Geriatricians Infectious … Inappropriate urinary catheter use may negatively affect the surgeon’s profile Risk of infection and trauma … They may lead to urinary tract infections and cause mechanical trauma to the urethra and bladder. … They also immobilize patients—increasing the likelihood of pressure ulcers, falls and prolonged inpatient

1449. ADHD-Update-protocol-160818 (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/adhd-update_research-protocol.pdf
      August 18, 2016 - growth suppression,24 weight decrease, sleep disturbance, gastrointestinal symptoms, elevated blood pressure … growth suppression, weight decrease, sleep disturbance, gastrointestinal symptoms, elevated blood pressure … Growth suppression • Weight decrease • Sleep disturbance • Gastrointestinal symptoms • Elevated blood pressure … suppression o Weight decrease o Sleep disturbance o Gastrointestinal symptoms o Elevated blood pressure

1450. Methods (continued, 2) | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamily3a.html
      July 01, 2018 - External motivation may also come from pressures or "pushes" from external organizations. … hospital-associated infections, reducing risk of harm from patient falls, and preventing hospital-associated pressure … unanticipated event in a health care setting resulting in death or serious physical or psychological injury … level (e.g., on PFACs and decisionmaking committees). 103,104 Sentinel events also lead to external pressures

1451. Noninvasive Testing for Coronary Artery Disease (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/coronary-artery-disease-testing_research-protocol.pdf
      January 15, 2015 - those related to local anesthesia and use of contrast material, as well as infection, local vascular injury … (FFR), which relies on the use of specialized catheters placed in the coronary artery to measure a pressure … BP = blood pressure; CABG = coronary artery bypass graft; CAD = coronary artery disease; DM = diabetes … This has been developed as an alternative to invasive FFR measurement in which a pressure wire is placed … Blood pressure and breathing are monitored as well. 22 Archived: This report is greater than 3 years

1452. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837959/psn-pdf
      August 31, 2022 - The patient developed generalized urticaria, bronchospasm requiring high airway pressures to achieve … Latex is essential to these plants to heal surface injuries and create immune responses against invading … Thus, unexplained hypotension, tachycardia, and high airway pressure for adequate ventilation (due to

1453. Final Progress Report: Risk Analysis of Pediatric Chemotherapy Processes (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/shenep-report.pdf
      January 01, 2024 - Review effectiveness of 60%. 6 Significant effect/ Minor injury Actual error occurred and reached … Page 8 8 Extreme effect/major injury Actual error occurred and reached the patient. … Error would result in a major injury for the individual served, including permanent patient harm … detect Remote likelihood that current controls will detect. 10 Catastrophic effect; terminal injury … Discussion Although CPOE is supported philosophically by multiple groups that exert significant pressure

1454. Final Progress Report: Process Reliability and Organizational Learning in Home Health Care (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/silver-report.pdf
      January 01, 2025 - Two hospitalizations (1.5%) were the result of injuries that were unrelated to home care. … 120 Decline resulting from patient's condition Complication of earlier care New diagnosis Injury … benefit will be provided in those visits (e.g., an agency cannot simply increase the frequency of wound … Identifying barriers to reporting changes in condition: unclear expectations, time/production pressure

1455. Making Healthcare Safer IV_Rapid Response: Use of Report Cards and Outcome Measurements To Improve the Safety of Surgical Care (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/mhs-IV-rapid-response-surgical-report-cards.pdf
      November 01, 2023 - infection, or other wound complication Making Healthcare Safer IV – Use of Report Cards and Outcome … embolism or deep vein thrombosis rate • PSI 13 – Postoperative sepsis rate • PSI 14 – Postoperative wound … Other independent predictors included injury severity score, systolic blood pressure, heart rate. … injury and 0.78 (0.51-1.06) for blunt multisystem injuries; changes sustained in 2009 O/E for all … multiple ICPs; Postoperative shower, skin prep technique, clean instruments/gowns/gloves for wound

1456. EMS Patient Safety in the Field | PSNet
      psnet.ahrq.gov/perspective/ems-patient-safety-field
      July 28, 2021 - correctly and safely, but for a subset of patients experiencing time-sensitive events such as severe trauma … To assist EMS personnel in decision making in high-pressure situations and to support standardized care … One example is injuries personnel can sustain from slipping or tripping when lifting and moving equipment … and patients. 8 An injury can harm not only the worker, but also the patient, if, for example, the … What if that trauma patient all of a sudden decompensated?

1457. Chartbook on Hispanic Health Care: Slide Presentation—Part 3 | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/hisph-slides-pt3.html
      May 01, 2018 - Slide 10 Adults who needed care right away for an illness, injury, or condition in the last 12 months … ) among Hispanics, 2002-2012 Image: Graphs show adults who needed care right away for an illness, injury … Slide 11 Children who needed care right away for an illness, injury, or condition in the last 12 … restrained daily can become weak, lose their ability to go to the bathroom by themselves, and develop pressure … Importance: Many patients who receive home health care are recovering from an injury or illness and

1458. 2023 National Healthcare Quality and Disparities Report Appendixes (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023-NHQDR-appendixes-ACDE-rev.pdf
      January 01, 2023 - 1,000 elective-surgery admissions, age 18 and over HCUP 2020 Reclosure of postoperative abdominal wound … 2020 Home health care patients whose management of oral medications improved OASIS 2021 Birth trauma … stages 2-4 pressure ulcer or unstageable pressure ulcer MDS 2021 Low-risk, long-stay nursing home … 2020 Home health care patients whose management of oral medications improved OASIS 2021 Birth trauma … stages 2-4 pressure ulcer or unstageable pressure ulcer MDS 2021 Low-risk, long-stay nursing home

1459. 2023 National Healthcare Quality and Disparities Report Appendixes (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023-NHQDR-appendixes-ACDE.pdf
      January 01, 2023 - 1,000 elective-surgery admissions, age 18 and over HCUP 2020 Reclosure of postoperative abdominal wound … 2020 Home health care patients whose management of oral medications improved OASIS 2021 Birth trauma … stages 2-4 pressure ulcer or unstageable pressure ulcer MDS 2021 Low-risk, long-stay nursing home … 2020 Home health care patients whose management of oral medications improved OASIS 2021 Birth trauma … stages 2-4 pressure ulcer or unstageable pressure ulcer MDS 2021 Low-risk, long-stay nursing home

1460. 2022 National Healthcare Quality and Disparities Report Appendixes (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2022qdr-appendix-combined.pdf
      October 25, 2022 - HCUP 2019 Home health care patients whose management of oral medications improved OASIS 2020 Birth trauma … pressure ulcer MDS 2019 Low-risk, long-stay nursing home residents with a catheter inserted and left … MDS 2019 Short-stay nursing home patients with pressure ulcers that are new or worsened MDS 2018 … HCUP 2019 Home health care patients whose management of oral medications improved OASIS 2020 Birth trauma … MDS 2019 Short-stay nursing home patients with pressure ulcers that are new or worsened MDS 2018