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461. Ed-Catheter-Insertions-Transcript (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/ed-catheter-insertions-transcript.doc
     September 10, 2013 - So because of his immobility, he developed a pressure ulcer on his sacrum and the physician decided to … Now we know the elderly are very vulnerable to infection and other injury in the hospital. … Possibly, the patient needs immobilization for trauma or surgery, patient is incontinent with open wounds … ; protocolized care for trauma; incontinence without open sacral or perineal wounds; pre-operative placement … On the next slide, we’ll – one case study is trauma.

462. Appendix A: Family Information Packet (continued) | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/resource/nicu/packet/apa3.html
     December 01, 2013 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

463. The National Action Alliance to Advance Patient Safety Summer Webinar Series - PowerPoint Presentation (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/action-alliance/public-action-alliance-slides-040323_LOCKED.pdf
     May 25, 2023 - factors focus areas • Workplace Change Collaborative – National Framework on Burnout and Moral Injury … “By and large, the U.S. does not account for medical care injuries and deaths in our vital statistics … Where it should say 'medical care harm/injuries', it's blank. … as surge … our new normal *Healthcare Acquired Infections, Early Elective Deliveries, Falls with Injury … , Healthcare Acquired Pressure Injuries, NTSV C-Section patients to get to WHO Goal, Sepsis Mortality

464. A Unit Guide To Infection Prevention for Long-Term Care Staff | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/guides/infection-prevent.html
     March 01, 2017 - Infections cause pain, injury, disability, and sometimes even death, and can be very expensive to treat … resident, if needed, that the law requires the use of safety lancets and needles to prevent needle stick injuries … Make sure that wounds are covered. Contain any urine, stool, or wound drainage. … An LTC facility must have negative pressure rooms and a respiratory fit-test program in order to safely … they are stressed or tired as they could be putting themselves at greater risk for an occupational injury

465. Organizational Behavior Management in Health Care: Applications for Large-Scale Improvements in Patient Safety (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Cunningham_11.pdf
     January 29, 2008 - percent).5 In terms of overall numbers, preventable technical complications of surgery (10,891) and wound … Postoperative wound dehiscence 15. Transfusion reaction Treatment 5. … Birth trauma and obstetric trauma (3 types related to delivery methods) Preventive 10. … as “response generalization.”36 This line of OBM research informed an intervention to decrease injuries … individual access to computers; d) adding clinical decision support; e) instigating relevant peer pressure

466. Do Transient Working Conditions Trigger Medical Errors? (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Grayson.pdf
     January 01, 2003 - .6, 10–12 Injuries to workers result from a causal chain of events involving both latent and immediate … Indeed, many risk factors for injury that have been studied in case-crossover studies of injury are … circumstances may be the result of other working conditions, such as a hectic work environment, time pressures … Case-crossover studies of occupational trauma: methodological caveats. … Injury Prevention 2001;7:Supplement 38–42.

467. Appendix B. Clinical Materials to Share With Primary Care Providers (continued) | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/resource/nicu/packet/apb3.html
     December 01, 2013 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … Gastric or esophageal trauma during placement. Gastrostomies: Granulation tissue (67%).

468. Chapter 1: Background on Patient Safety and LEP Populations | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/health-literacy/professional-training/lepguide/chapter1.html
     September 01, 2020 - Adverse event*: Any injury caused by medical care. … include pneumothorax from central venous catheter placement, anaphylaxis to penicillin, postoperative wound … Similarly, postoperative wound infections count as adverse events even if the operation proceeded with … Near miss/close call * : An event or situation that did not produce patient injury, but only because … LEP patients are at greater risk of line infections, surgical infections, falls, and pressure ulcers

469. Module 3: Best Practices in Fall Prevention (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module3/module3_fall-prevention.docx
     January 01, 2013 - Prevention Program Training Webinar Post-Fall Huddles: Reducing Preventable Falls and Fall-Related Injuries … medications or medicines that could cause sedation, confusion, impaired balance, or orthostatic blood pressure … The patient should be carefully and systematically assessed for injuries. … The post-fall clinical review focuses on immediate risk of injury or complications. … RCA is often used for a fall with injury.

470. Module 2: How To Manage Change—Training Guide | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-2/guide.html
     September 01, 2017 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … applied to other quality improvement efforts in a hospital, such as preventing: Hospital-acquired pressure … injuries.

471. Webinar 2: Analyze Data and Patient/Caregiver Perspectives (Section 1 of the Guide): Slide Presentation | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/resource/guide/web2.html
     December 01, 2017 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

472. Tool 1: Overview | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool1.html
     March 01, 2013 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

473. 2019 National Healthcare Quality and Disparities Report Quality Trends (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr-core-measures-quality.pdf
     January 01, 2019 - 51.9% in 2013 67.7% in 2017 -9.5 0.006 Surgical Safety Home health care patients whose surgical wound … single measure that was not changing over time examines long-stay nursing home patients who experience injuries … Ulcers Short-stay nursing home patients with new or worsening pressure ulcers (MDS) 0.7% in 2013 … Ulcers High-risk, long-stay nursing home patients with pressure ulcer (MDS) 5.3% in 2013 4.8% in … 2017 -2.1 0.018 Falls Long-stay nursing home patients experiencing one or more falls with major injury

474. Emergency Department and Catheter Insertion | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/cauti-tools/archived-webinars/ed-catheter-insertions-transcript.html
     December 01, 2017 - So because of his immobility, he developed a pressure ulcer on his sacrum and the physician decided to … Now we know the elderly are very vulnerable to infection and other injury in the hospital. … Possibly, the patient needs immobilization for trauma or surgery, patient is incontinent with open wounds … ; protocolized care for trauma; incontinence without open sacral or perineal wounds; pre-operative placement … On the next slide, we’ll – one case study is trauma.

475. Effect of Recent Refresher Training on in Situ Simulated Pediatric Tracheal Intubation Psychomotor Skill Performance (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Nishisaki_44.pdf
     April 19, 2008 - • Hypotension: systolic blood pressure <70 mmHg.9 • Intubation failure: o No intubation success … Nadkarni); the Center for Injury Research and Prevention (Dr. … Committee on Trauma. Advanced trauma life support student manual. 7th ed. … The infant has no evidence of increased intracranial pressure. … Each subject was reminded to “pay attention to” the potential cervical spine injury, but a person was

476. Appendix D. Falls Engineer Instructions | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapd.html
     December 01, 2017 - Patient Safety Patient Safety Resources by Setting Long Term Care Resources Injuries … Engineer Instructions The Falls Management Program is designed to prevent falls and injuries … Fill to the pressure recommended on the side of the tire. … Instructions: If the brake lever does not bite 1/8 inch into the tire, it may be because the tire pressure … https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapd.html

477. Module 8: Organizational Learning and Sustainability | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes8.html
     August 01, 2022 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

478. Communication: Obstetric Hemorrhage - PowerPoint Presentation
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_3_communication.pptx
     July 01, 2023 - interruption to a doctor who is with a patient's family members. 2 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, … Her blood pressures have remained normotensive, and she has had good reflexes throughout the shift. … Her blood pressures have remained normotensive, and she has had good reflexes throughout the shift.” 

479. Mercy Health Uses AHRQ's Patient Safety Culture Survey and TeamSTEPPS® to Enhance Care | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/news/newsroom/case-studies/201411.html
     August 01, 2014 - Mercy also replaced patient beds to reduce incidents of pressure ulcers and to promote patient and staff … Implementing the "Minimal Lift Program," which is designed to reduce injuries resulting from repositioning

480. Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/findings/studies/index.html
     January 01, 2024 - Autism (31) Back Health and Pain (58) Behavioral Health (699) Blood Clots (62) Blood Pressure … (132) Blood Thinners (79) Brain Injury (64) Breast Feeding (18) Burnout (64) Cancer … (255) Imaging (245) Implementation (191) Infectious Diseases (260) Influenza (41) Injuries … and Wounds (207) Inpatient Care (221) Intensive Care Unit (ICU) (267) Kidney Disease and … Tools & Toolkits (49) Training (143) Transitions of Care (192) Transplantation (141) Trauma