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1501. DARTNet Summary Report (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/distributed-network-ambulatory-therapeutics_research.pdf
      July 01, 2009 - Rates of hypoglycemia, liver injury, and liver failure were rare, and did not differ substantially … claims  Medication allergies  Reason for appointment  Family history  Findings (blood pressure … Rates of hypoglycemia, liver injury, and liver failure were determined from EHR data. … As was the case in Phase 1, rates of hypoglycemia, liver injury, and liver failure were rare and did … the exception of a few values not represented in administrative data (e.g., height, weight, blood pressure

1502. NAA National Webinar July 2024 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/slides-healthcare-safer-by-design.pdf
      August 20, 2024 - Use of an ADC’s override feature should be routinely tracked and monitored. 2023 #6 Inflatable Pressure … ©2024 ECRI | ECRI Confidential47 Surgical Fire Response • Immediate action • Mitigate risk of injury

1503. 2019NHQDRMethodsReport (pdf file)
      hcup-us.ahrq.gov/reports/methods/2020-04.pdf
      January 01, 2020 - • ED visits for injuries. … ED utilization for injuries was reported by trauma level and by age, sex, community income, urban-rural … PSI03 Admissions with pressure ulcers per 1,000 medical and surgical discharges of length 3 or more … QI QI Label Definition Footnote Risk Adjustment Footnote PSI15 Reclosure of postoperative abdominal wound … PSI18 Birth trauma - injury to neonate per 1,000 live birthsa,b a Consistent with the AHRQ PSI software

1504. In Conversation With…David C. Classen, MD, MS | PSNet
      psnet.ahrq.gov/perspective/conversation-withdavid-c-classen-md-ms
      May 01, 2012 - detection of adverse events in hospital patients, and it moves patient safety from a retrospective focus on injury … a really important transition to make, and it's going to be hard because it's going to put a lot of pressure … estimated that avoidable medical errors contribute to 44,000–98,000 deaths, and more than a million injuries … Patient safety efforts should focus on medical injuries. JAMA. 2002;287:1993-1997.

1505. The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety | PSNet
      psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-patient-safety
      May 01, 2012 - estimated that avoidable medical errors contribute to 44,000–98,000 deaths, and more than a million injuries … Patient safety efforts should focus on medical injuries. JAMA. 2002;287:1993-1997. … detection of adverse events in hospital patients, and it moves patient safety from a retrospective focus on injury … a really important transition to make, and it's going to be hard because it's going to put a lot of pressure

1506. Microsoft Word - 3-DKE274__ACEI-ARB-DRI__Comments_Disposition_Table-21_Jan_2011 cyk _2_.docx (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/ace-inhibitor-arb-update_disposition-comments.pdf
      October 07, 2011 - the second and third trimesters, drugs that act directly on the renin angiotensin system can cause injury … This would be appropriate for blood pressure control and perhaps for adherence to medication and common … Some of our outcomes of interest, such as blood pressure lowering or medication side effects, could

1507. Evidence-based Practice Center Systematic Review Protocol (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/health-literacy_research-protocol.pdf
      January 22, 2010 - Health literacy, morbidity, and quality of life among individuals with spinal cord injury. … Discharge knowledge and concerns of patients going home with a wound. … J Wound Ostomy Continence Nurs 2007;34:245-53. … Literacy and blood pressure—do healthcare systems influence this relationship? … Comprehension of discharge information for minor head injury: a randomised controlled trial in New Zealand

1508. Behavioral Programs for Diabetes Mellitus (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/diabetes-behavior-programs_executive.pdf
      September 11, 2015 - , and cholesterol levels.14,22-24 For instance, intensive lowering of blood pressure in people with … For patients with T1DM, what are the associated harms (i.e., activity-related injury) of behavioral … For KQ 4, harms (i.e., activity-related injury), we planned to descriptively summarize all outcomes … No studies reported on the associated harms (i.e., activity-related injury) of behavioral programs … For objective outcomes (e.g., HbA1c, weight, blood pressure), 42 percent of trials had a medium risk

1509. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865884/psn-pdf
      May 29, 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

1510. Research on the Integration of Behavioral Health in Primary Care webinar
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/webinars/behavioral-health-primary-care-webinar.pptx
      March 07, 2024 - I would’ve never thought to refer him to it because of the level of his brain injury” Tack, E., Lakhtakia … There are key SSDOH in driving blood pressure disparities for example, like lack of access to healthy

1511. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866618/psn-pdf
      December 31, 2024 - On arrival at the ED, he was afebrile, heart rate was 98 beats per minute (bpm), blood pressure was … especially in busy clinical settings such as the ED.2–4 Hemolysis is defined as a generalized process of injury

1512. Making Healthcare Safer IV_Rapid Review: Use of Structured Handoff Protocols for Intrahospital Within-Unit Transitions (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/structured-handoff-rapid-research.pdf
      January 01, 2025 - IMIST-AMBO (identification/introduction, mechanism of injury/medical complaint, injuries/information … IMIST-AMBO = identification/introduction, mechanism of injury/medical complaint, injuries/information … transitions of care: healthcare handoffs in trauma. … injuries and medication administration errors: an integrative review. … injuries and medication administration errors: an integrative review.

1513. Disabilities-Quality-Improvement-Outcomes Executive (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/disabilities-quality-improvement-outcomes_executive.pdf
      October 01, 2012 - Patients include those with temporary disability due to trauma or illness and those with “stable” disabling … categories of disability etiology/timing of onset are: congenital/ developmental, acquired (disease or trauma … including: 8 • Preventive dental care • Preventive medical care • Urinary tract infections • Pressure … Aging with spinal cord injury. Phys Med Rehab Clin N Am. 2010 May;21(2): 383-402. … Brain Injury. 2011;25(1):83-100. 36. Petry K, Maes B, Vlaskamp C.

1514. Optimize Briefings and Debriefings: Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/surgery/modules/implementation/opt-briefings-fac-notes.html
      December 01, 2017 - defines a sentinel event as an unexpected occurrence involving death or serious physical or psychological injury … Serious injury specifically includes loss of limb or function. … Review the perfusion plan, including cannulation, perfusion pressure goals, temperature, and transfusion

1515. A Fatal Twist in Pseudohyperkalemia | PSNet
      psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
      February 10, 2021 - On arrival at the ED, he was afebrile, heart rate was 98 beats per minute (bpm), blood pressure was 103 … especially in busy clinical settings such as the ED. 2–4 Hemolysis is defined as a generalized process of injury … WebM&M Cases Intraosseous Line Extravasation in a Pediatric Trauma

1516. Cesarean Delivery for Nulliparous (NTSV) Women (Appropriate Use) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/perinatal/chipra-0082-fullreport.pdf
      March 01, 2016 - delivery are at much higher risk for rehospitalization for uterine infection and obstetrical surgical wound … nonmedical factors such as provider density, the capacity of the local health care system, and malpractice pressure … o Have a physical abnormality or injury to their brain or spinal cord. … For example, there may be fewer surgical injuries and fewer infections. … vaginally is more likely to have a nerve injury that affects the shoulder, arm, or hand.

1517. Which Line: Ordering Provider or Proceduralist? | PSNet
      psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
      September 16, 2015 - 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

1518. Privacy or Safety? | PSNet
      psnet.ahrq.gov/web-mm/privacy-or-safety
      December 01, 2011 - patient on the same unit who also happened to have severe cognitive impairment from a traumatic brain injury … Evaluation of the suitability of root cause analysis frameworks for the investigation of community-acquired pressure

1519. Duty to Disclose Someone Else's Error? | PSNet
      psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error
      June 01, 2004 - 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

1520. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50754/psn-pdf
      December 18, 2019 - an unwanted resuscitation with extreme consequences, including CPR- related fractures, anoxic brain injury … establishing more humane working hours during postgraduate training, residents are still often under great pressure