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961. In Conversation With… Paul H. O'Neill, MPA | PSNet
     psnet.ahrq.gov/perspective/conversation-paul-h-oneill-mpa
     January 01, 2017 - their workforce, I announced we should be an injury-free workplace. … And over the 13 years I was there we got close to achieving zero injuries. … safety, namely to identify as quickly as possible anything gone wrong—including medication errors, pressure … are probably no better than average at all the other things they do, like central line infections and pressure … Were there time pressures in the OR to proceed with no help?

962. Communication: Severe Hypertension (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_3-communication-speaker-notes.pdf
     July 01, 2023 - patient's family members. 4 Hospital AIM Team Leads SPPC‐II Maternal and Perinatal Deaths and Injuries … communication breakdowns are identified as the primary root cause of maternal and perinatal deaths and injuries … Other root causes for maternal and perinatal deaths and injuries are— • Assessment (i.e., the adequacy … Severe‐range blood pressure was sustained for nearly an hour. Ms. … Untitled Communication Severe Hypertension Communication is… Maternal and Perinatal Deaths and Injuries

963. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits Training | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereport-slides.html
     September 01, 2017 - showing 15 active medications during the report week, active high-risk diagnosis of UTI, stage III pressure … DNR,DNH, MOLST, or POLST Order in Place Oxygen Therapy Catheter or Ostomy Present Stage II or > Pressure … Gastrointestinal/ Genitourinary Symptoms Endocrine/ Metabolic/ Nutrition Issues Wound … Genitourinary Endocrine/ Nutritional/ Metabolic Musculoskeletal/ Joint Symptoms Wound … Circulatory Problems Hypertension or Renal Failure Gastroenteritis Angina Pectoris Falls /Trauma

964. Table 17F: HCBS Population Ages 18-64 Without Intellectual/Developmental Disabilities or Serious Mental Illness | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17f.html
     February 01, 2023 - 7,139 5,429 Composite: ACSC Overall 23,940 16,507 25,790 18,529 23,803 18,978 Pressure … 147 123 175 119 170 116 Outcome Indicator Prevalence of High Blood Pressure … 6,119 6,072 7,171 5,539 Composite: ACSC Overall 21,607 19,235 23,468 19,546 Pressure

965. Table 17E: Serious Mental Illness Subpopulation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17e.html
     February 01, 2023 - 8,838 5,914 Composite: ACSC Overall 20,734 15,368 19,563 17,756 23,009 16,087 Pressure … 253 224 263 220 323 194 Outcome Indicator Prevalence of High Blood Pressure … 6,956 7,098 7,925 6,580 Composite: ACSC Overall 19,175 17,427 20,509 17,826 Pressure

966. Delayed Evaluation of Abdominal Pain in an Elderly Patient. | PSNet
     psnet.ahrq.gov/web-mm/delayed-evaluation-abdominal-pain-elderly-patient
     February 26, 2020 - The patient remained alert and cooperative until 2350H when her blood pressure fell to 90/58. … Nevertheless, every patient deserves to be provided with the best opportunity to survive an illness or injury … that permits all necessary interventions to be provided commensurate with the degree of illness or injury … Consulting Editor, AHRQ’s Patient Safety Network (PSNet) Professor Department of Surgery Division of Trauma … 2022 WebM&M Cases Errors in Managing an Open Wound

967. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/851971/psn-pdf
     July 31, 2023 - with factitious disorder consciously and manipulatively (usually surreptitiously) produce illness or injury … advocated by most experienced practitioners.20 Applying cricoid pressure compresses the esophagus and … this communication error because the foreign body likely traversed the gastrointestinal tract without injury … Scand J Trauma Resusc Emerg Med. 2021;29(1):64. [Free full text] 20. … The clinical use of cricoid pressure: first, do no harm. Anesth Analg. 2021;132(1):261-267.

968. renal-update-2015-150115 (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/pdf/renal-update_research-protocol.pdf
     January 15, 2015 - channel blockers, and/or beta blockers, is frequently prescribed with a goal of normalizing blood pressure … [Type text] [Type text] [Type text] pressure … *5th Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (1993). … Blood pressure outcome of angioplasty in atherosclerotic renal artery stenosis: a randomized trial. … Critical lesion.af. 16. exp Acute Kidney Injury/ 17.

969. Final Topic Refinement Document - Therapeutic Options for Obesity in the Medicare Population (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/obesity_topic-refinement.pdf
     May 22, 2014 - Adverse effects of interventions ● Activity-related injury ● Adverse effects of medication ( diarrhea … Respiratory disease (i.e., asthma, COPD) ● Sleep apnea o BMI o Adverse effects ● Activity-related injuries … Question 1b CMS Intermediate outcomes We are excluding all intermediate outcomes (adherence, blood pressure … outcomes CMS Intermediate outcomes We are excluding all intermediate outcomes (adherence, blood pressure … skinfold thickness and waist circumference; excluding all intermediate outcomes (adherence, blood pressure

970. Update on Methods: Insufficient Evidence | United States Preventive Services Taskforce
     www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/update-methods-insufficient-evidence
     March 04, 2021 - take up the time available to discuss smoking cessation, or to address an acute problem or a minor injury … Contrast: Application to Screening for High Blood Pressure in Adolescents   Screening for high blood … Considering this information, a clinician might decide in favor of assessing blood pressure routinely … Preventive Services Task Force Recommendation on High Blood Pressure Screening, 2003. … Recommendations for Adults: Heart and Vascular Diseases: Screening for High Blood Pressure.

971. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/852280/psn-pdf
     August 09, 2023 - Veterans Health Administration (VHA) hospital, this study found that use of SmartSocks – socks containing pressure … assessment-wearable-fall-prevention-system-veterans-health-administration-hospital https://psnet.ahrq.gov/primer/falls https://psnet.ahrq.gov/issue/preventing-falls-injury

972. Methods Applying AHRQ Quality Indicators to Healthcare Cost and Utilization Project (HCUP) Data for the Tenth (2012) NHQR and NHDR (pdf file)
     hcup-us.ahrq.gov/reports/methods/2012-02.pdf
     January 01, 2012 - E Codes: Another issue relates to external cause-of-injury reporting. … data to help identify complications of care or to exclude cases (e.g., poisonings, self-inflicted injury … , delirium and other psychoses, anoxic brain injury; patients with metastatic cancer, lymphoid malignancy … , bone malignancy, and self-inflicted injury; admissions for diseases and disorders of the musculoskeletal … PSI 17 Birth trauma - injury to neonate per 1,000 live births (excluding preterm and osteogenesis imperfecta

973. Quantitative and Qualitative Analysis of Medication Errors: The New York Experience (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Duthie.pdf
     January 01, 2004 - mandatory error reporting programs gather data on errors associated with fatal outcomes or serious injuries … of administration were trapped prior to completion.10 The population above age 65 sustained more injuries … The most significant potential for injury occurred in the transition of a patient across and between … Inaccurate or incomplete data about medication regimens, when undetected, caused patient injuries. … Time pressures—due to limited CT scanner availability; the critical nature of the patient’s condition

974. Table 7: Health and Welfare of the Home and Community-Based Services Population as Measured by 13 Outcome Indicators, 2005 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab7.html
     December 01, 2012 - 5,672 13,799 7,174   Max 38,852 29,161 10,824 48,675 50,219 49,623 36,143 Pressure

975. Standardized infection ratios for central line-associated bloodstream infections and surgical site infections, 2009–2012
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/healthyliving/qdr2015-chartbook-healthyliving.pptx
     January 01, 2020 - Nerve injury not elsewhere classified at birth, and Birth trauma not elsewhere classified.24 Many … of these injuries to neonates may be preventable.25 41 Birth trauma—injury to neonate per 1,000 … Overall Rate: In 2013, the birth trauma-neonatal injury rate was 1.9 per 1,000 live births. … Between 2004 and 2013, birth trauma-neonatal injury rates fell for all racial/ethnic groups, except for … Birth Trauma Rate—Injury to Neonate: Technical Specifications.

976. Survey on Patient Safety (facility version) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.pdf
     June 02, 2025 - • “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events … Whenever pressure builds up, my supervisor/manager wants us to work faster, even if it means taking

977. Survey on Patient Safety (facility version) (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
     June 02, 2025 - · “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events … Whenever pressure builds up, my supervisor/manager wants us to work faster, even if it means taking shortcuts

978. 52-Regional-Analgesia-Arthroplasty-Facilitator (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/52-regional-analgesia-arthroplasty-facilitator.docx
     June 01, 2023 - Neuraxial blocks can lead to decreased blood pressure and profound motor nerve block, which may not be … of regional analgesia in the setting of anticoagulation to avoid the potential risk of neurological injury

979. Nurses' use of computerized clinical guidelines to improve patient safety in hospitals. | PSNet
     psnet.ahrq.gov/issue/nurses-use-computerized-clinical-guidelines-improve-patient-safety-hospitals
     June 06, 2018 - February 14, 2024 A randomized trial of a multifactorial strategy to prevent serious fall injuries … May 29, 2019 Medical device-related pressure ulcers: a systematic review and meta-analysis

980. Check the Anesthesia Machine | PSNet
     psnet.ahrq.gov/web-mm/check-anesthesia-machine
     August 01, 2006 - are difficult to compare, current estimates put medication error rates at 1 in 100 anesthetics.( 2 ) Injury … from such errors are estimated to occur with 1% of errors.( 3 ) By extrapolation, then, the risk of injury … American Society of Anesthesiologists Closed Claims Project recently presented an update on patient injuries … Medication error etiology is multifactorial and includes a distracting environment and production pressure … Patient injuries from anesthesia gas delivery equipment: a closed claims update.