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  1. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Hunt.pdf
    July 01, 2004 - This urgency is, in part, precipitated by the confluence of market pressures to demonstrate value in … DVT/PE* Hospital acquired UTI** Ventilator associated pneumonia** Adverse drug events ** Pressure … care postoperative stays has shifted the diagnostic location for a large percentage of postoperative wound … reliable proxies for this event in the administrative claims, our ability to identify postoperative wound … A study of medical injury and medical malpractice: an overview.
  2. ce.effectivehealthcare.ahrq.gov/news/newsletters/e-newsletter/866.html
    May 01, 2023 - disorders, bipolar and related disorders, suicidal ideation or attempt or intentional self-harm, and trauma … include: Implementing an electronic root cause analysis reporting system to decrease hospital-acquired pressureinjuries.
  3. ce.effectivehealthcare.ahrq.gov/es/patient-safety/settings/hospital/resource/nicu/coaching.html
    December 01, 2013 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit PressureInjury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI
  4. ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/resource/nicu/packet/apa2.html
    December 01, 2013 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit PressureInjury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI
  5. ce.effectivehealthcare.ahrq.gov/research/findings/studies/index.html?page=0
    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 (63) Cancer … (253) Imaging (245) Implementation (191) Infectious Diseases (260) Influenza (41) Injuriesand Wounds (207) Inpatient Care (220) Intensive Care Unit (ICU) (264) Kidney Disease and … Tools & Toolkits (49) Training (143) Transitions of Care (192) Transplantation (141) Trauma
  6. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Weinberg.pdf
    March 01, 2004 - In this research, we examined State legislative responses to pressure from constituents and policymakers … or disability or the immediate danger of serious injury or disability”); and Class C (an adverse event … Nevada defines a sentinel event as “an unexpected occurrence” involving death or serious injury or the … According to JCAHO, the classification of an AE that was avoided or did not result in injury is drawn … In recent years, State legislatures have deflected pressure to regulate health care away from the Federal
  7. ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-4/guide.html
    October 01, 2017 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit PressureInjury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … Critical Thinking for Fall Injury Prevention —AHRQ Fall Prevention Program Implementation Sharing Webinar
  8. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
    November 15, 2019 - · “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
  9. ce.effectivehealthcare.ahrq.gov/research/findings/making-healthcare-safer/comparison.html
    September 01, 2022 - Evidence (Not reviewed) (Not reviewed) Interventions To Prevent Contrast-Induced Acute Kidney Injury … Summary of Evidence Update (all patients) (Not reviewed) Preventing Patient Death or Serious Injury … Institutionalized Older People Summary of Evidence Update (all patients) (Not reviewed) Prevention of Pressure
  10. ce.effectivehealthcare.ahrq.gov/news/newsletters/e-newsletter/861.html
    April 01, 2023 - The COVID-19 pandemic has intensified these pressures. … J Trauma Acute Care Surg 2023 Apr;94(5):592-8. Epub 2023 Nov 18. … Renal outcomes following intravenous contrast administration in patients with acute kidney injury: a
  11. ce.effectivehealthcare.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html
    June 01, 2022 - The Preventing Pressure Ulcers in Hospitals Toolkit assists hospital staff in implementing effective … pressure ulcer prevention practices through an interdisciplinary approach to care. … The toolkit draws on literature on best practices in pressure ulcer prevention and includes both validated … patients can suffer adverse outcomes and even fatal complications, and clinicians can be exposed to injury
  12. Paul Tedrick (doc file)

    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/building-team-transcript.doc
    April 08, 2014 - The fourth indication is the healing of open wounds that are close to the groin area. … , such as a motor vehicle accident where they have an injury to the spinal cord. … Assisting healing with a perineal or sacral wound in certain patients. … or multiple traumatic injuries, such as multiple fractures, and you worry that, again, movement will … Wound care nurses, we talked about, the pressure associated with the Foley catheter is helping.
  13. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flack.pdf
    January 01, 2005 - 519, mandates that all manufacturers of medical devices must report device-related deaths, serious injuries … facilities” must report medical device related deaths to FDA and to the manufacturer and report serious injuries … of medical devices so it could become more proactive in addressing device issues before a death or injury … the various types and sizes of facilities that are obligated to make reports of deaths and serious injuries … systems are really at the root of the problem, and c) clinicians report they are just too busy with the pressures
  14. ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apviia.html
    June 01, 2010 - Effectiveness Reviews Facilities Home and Community Resources Findings Report Injuries … of State Directors of Developmental Disabilities Services, the National Associations of State Brain Injury … agencies, units on aging, agencies serving individuals with physical disabilities, traumatic brain injury … Medicaid-eligible individuals who are frail and elderly, have intellectual and developmental disabilities, head injuries … future and the "Never Events," I did not see any use of the never events, including: Stage 3 or 4 pressure
  15. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.pdf
    November 18, 2019 - • “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
  16. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/coordination/ccqmpc/cati-script.pdf
    July 01, 2016 - able to walk a flight of stairs without losing your breath, or target rates —for example, a blood pressure … In the last 12 months, if you had an illness or injury, how often did your primary care provider or … professionals in this office ask whether you had enough services to help you take care of this illness or injury … NEEDED] 1 Never 2 Sometimes 3 Usually 4 Always, or 5 I did not have an illness or injury … High blood pressure or hypertension? 66e. Congestive heart failure? 66f.
  17. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module2/module2_slides_fallprev.pptx
    August 24, 2017 - Process Change process strategies can be applied to other quality improvement efforts: Hospital-acquired pressureinjuries Catheter-associated urinary tract infections Deep vein thrombosis or pulmonary embolism following
  18. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.doc
    June 09, 2016 - · “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
  19. ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm7.html
    October 01, 2014 - Effectiveness Reviews Facilities Home and Community Resources Findings Report Injuries … self-reporting is an invalid and unreliable way to collect data on clinical indicator values, such as blood pressure … Blood pressure test at every continuing care visit. … A State interested in tracking pressure ulcers in its Supplemental Security Income (SSI) population, … contains hybrid specifications for measures such as cholesterol management, controlling high blood pressure
  20. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kizer1.pdf
    April 01, 2004 - Not surprisingly, health care errors and consequent adverse events are a leading cause of death and injury … Introduction Health care errors and consequent adverse events are a leading cause of death and injury … Evaluate each patient upon admission, and regularly thereafter, for his or her risk of developing pressure … contrast media-induced renal failure, and use a clinically appropriate method for reducing risk of renal injury … Use of specialized hospital flooring to reduce injury from patient falls. 3.

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