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621. Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/publications/files/lepguide.pdf
     September 01, 2012 - 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 … Teamwork training improves the clinical care of trauma patients. … About 30 minutes later, he begins to develop some chest pressure, which he had not noticed before.

622. Patient Safety Tools | Agency for Healthcare Research and Quality
     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

623. Organizational Climate of Staff Working Conditions and Safety—An Integrative Mode (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Stone.pdf
     January 01, 2004 - as likely as nurses on well-staffed and better-organized units to report risk factors, needlestick injuries … Implementing evidence-based medicine: the role of market pressures, compensation incentives, and culture … Effects of hospital staffing and organizational climate on needlestick injuries to nurses.

624. Sustainability: Learning From Defects: Facilitator Notes | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-fac-notes.html
     December 01, 2017 - If someone is in danger of injury or an emergent procedure is missing a vital resource, we do what needs … Were decisions made under pressure, despite distractions, or without appropriate knowledge of case or

625. Prescribing Safety in Ambulatory Care: Physician Perspectives (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Rundall.pdf
     January 01, 2003 - Human: Building a Safer Health System, identified medical errors as a leading cause of death and injury … control … and we’re treating 85-year-olds with drugs that will knock them out just to lower their blood pressure

626. Improving the Value of Patient Safety Reporting Systems (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Pronovost_95.pdf
     June 12, 2008 - identified insufficient staff knowledge as the main cause of events related to the use of intracranial pressure … Severity scoring (i.e., severity of patient injury and frequency of occurrence) is one approach to prioritizing

627. High-Hanging Fruit: Improving Transitions in Health Care (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-Perry_49.pdf
     March 27, 2008 - Signovers provide more than information (e.g., name, blood pressure, diagnosis); they also support macrocognitive … Patterns of communication breakdowns resulting in injury to surgical patients.

628. 2021 National Healthcare Quality and Disparities Report Data Sources (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2021qdr-datasources.pdf
     December 31, 2021 - state-specific data on preventive health practices and risk behaviors linked to chronic diseases, injuries … patient’s age, gender, race, and ethnicity; patient’s expressed reason for visit; intentionality of injury … include mode of arrival, waiting time, duration of time in the ED, initial vital signs, and cause of injury … The examination includes physical measurements, such as blood pressure and dental examinations, and … from each family in the house and collects data on topics including health status and limitations, injuries

629. Fallspximpl-Handouts (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/fallspximpl-handouts.docx
     November 15, 2017 - The On-Time reports may also take some of the pressure off communication practices by automatically providing … She did make a recommendation for a medication change and some increased monitoring of blood pressure

630. 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.

631. 2019 National Healthcare Quality and Disparities Report Data Sources (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr-datasources.pdf
     December 01, 2020 - state-specific data on preventive health practices and risk behaviors linked to chronic diseases, injuries … The examination includes physical measurements, such as blood pressure and dental examinations, and … from each family in the house and collects data on topics including health status and limitations, injuries … infections; seven types of adverse events associated with surgery; patient falls; and hospital-acquired pressure … events associated with the hospital stay and not present on hospital admission (inpatient falls and pressure

632. Barriers Associated with Medication Information Handoffs (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Bayley.pdf
     January 01, 2004 - actually access information from other settings varies with patient complexity, patient acuity, and time pressures … This reflects their focus on immediate treatment and stabilization of an acute illness or injury. … definitions are not personal failures as much as imperatives caused by the organizational structure and the pressures

633. Identifying, Understanding, and Communicating Medical Device Use Errors: Observations from an FDA Pilot Program (pdf file)
     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

634. Appendix VII: Public Comments Submitted Between March 7 and March 21, 2008 (continued) | Agency for Healthcare Research and Quality
     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

635. Survey on Patient Safety (facility version) (pdf file)
     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

636. Care Coordination Quality Measure for Primary Care (CCQM-PC) (pdf file)
     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.

637. How To Manage Change
     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 pressure … injuries Catheter-associated urinary tract infections Deep vein thrombosis or pulmonary embolism following

638. Hospital Survey on Patient Safety (doc file)
     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

639. Section 7: Measuring Value in a Care Management Program | Agency for Healthcare Research and Quality
     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

640. Safe Practices for Better Health Care (pdf file)
     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.