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641. 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

642. Final Progress Report: TOP-MEDS CERT: Tools for Optimizing Medication Safety (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-01/lambert-report.pdf
     January 01, 2024 - Antidepressant treatment and suicide attempts and self-inflicted injury in children and adolescents. … Antidepressant treatment and suicide attempts and self-inflicted injury in children and adolescents … also investigate our strategy’s impact on intermediary clinical outcomes, including systolic blood pressure … measures included medication understanding, adherence, and clinical measures (hemoglobin A1c, blood pressure

643. 2017Qdr-Patsafchartbook (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/2017qdr-patsafchartbook.pdf
     October 01, 2018 - per 1,000 instrument-assisted deliveries • Birth trauma - injury to neonate per 1,000 selected live … 40 60 80 100 2014 2015 2016 2017 2018 2019 GOAL Ra te p er 1 ,0 00 D is ch ar ge s Pressure … 40 60 80 100 2014 2015 2016 2017 2018 2019 GOAL Ra te p er 1 ,0 00 D is ch ar ge s Pressure … Adverse Drug Events • An adverse drug event (ADE) is an injury—including physical harm, mental harm, … The home health team should regularly change wound dressing and teach the patient about wound care.

644. 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

645. 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.

646. PowerPoint Presentation: Learn From Defects for Sustainability
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects.pptx
     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

647. Universal ICU Decolonization: An Enhanced Protocol (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/publications/files/universalicu.pdf
     September 01, 2013 - Wound Care 1. For what types of wounds is chlorhexidine (CHG) application safe? … to avoid causing additional soft tissue damage or extension of the wound due to pressure against the … #2: Nasal Trauma  Do NOT use mupirocin if nostril(s) are packed. …  CHG will not harm occlusive dressing (e.g., wound vacs).  Do NOT use on large or deep wounds … CHG can cause permanent injury if it comes in direct contact with nerves and is allowed to remain there

648. Simulation-Based Education Improves Patient Safety in Ambulatory 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-Lavelle_33.pdf
     March 12, 2008 - related to pediatrics, respiratory emergencies, and seizures, the urgent care staff also requested trauma … scenarios (e.g., lacerations, fractures, head injuries, spinal cord injuries). … to obtain a more easily transportable, moderate-fidelity manikin with heart/lung sounds and blood pressure

649. AHRQ Safety Program for Perinatal Care Summary Report (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/sppc-summary_report.pdf
     May 01, 2017 - Rate-Injury to Neonate o Obstetric Trauma Rate-Vaginal Delivery With Instrument o Obstetric Trauma … Rate-Injury to Neonate (AHRQ Patient Safety Indicator 17) • Obstetric Trauma Rate-Vaginal Delivery … With Instrument (AHRQ Patient Safety Indicator 18) • Obstetric Trauma Rate-Vaginal Delivery Without … , they sustained the use of TeamSTEPPS tools and techniques through peer support and positive peer pressure … • More favorable changes in the obstetric trauma with instruments measure (PSI 18) for units with

650. Return on Investment Tool (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/f1_combo_returnoninvestment.docx
     January 01, 2013 - For example, improvement actions might reduce hospital-associated infections, rates of pressure ulcers … Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization

651. INSTRUCTIONS: Return on Investment Estimation (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/f1-returnoninvestment.pdf
     January 01, 2009 - For example, improvement actions might reduce hospital-associated infections, rates of pressure ulcers … Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization

652. 43-Pathway-Worksheet (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/43-pathway-worksheet.docx
     June 01, 2023 - record systems have clinical decision support that can be helpful in flagging triggers (e.g., low blood pressure … Tidal volumes of 6–8 mL/kg of predicted body weight with positive end expiratory pressures of 5 cm H2O … approach: Intraoperative tidal volume 6–8 mL/kg of predicted body weight with positive end expiratory pressures … All ISCR Pathways Wound Protector Use Recommended approach: Wound protectors are recommended for all … is drinking liquids unless the patient has difficulty with oral intake, there is evidence of kidney injury

653. Return on Investment Tool (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/f1_combo_returnoninvestment.pdf
     January 01, 2013 - For example, improvement actions might reduce hospital-associated infections, rates of pressure ulcers … Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization

654. 2022 National Healthcare Quality and Disparities Report Data Sources (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2022qdr-datasources.pdf
     December 01, 2022 - 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 … patient’s age, gender, race, and ethnicity; patient’s expressed reason for visit; intentionality of injury … ulcer adverse events Pressure Ulcer Venous thromboembolism/pulmonary embolism (VTE/PE) not related

655. 2023 National Healthcare Quality and Disparities Report Data Sources (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023qdr-data-sources.pdf
     December 01, 2023 - state-specific data on preventive health practices and risk behaviors that are linked to chronic diseases, injuries … from each family in the house and collects data on topics including health status and limitations, 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 … ulcer adverse events Pressure Ulcer Venous thromboembolism/pulmonary embolism (VTE/PE) not related

656. Implementing Near-Miss Reporting and Improvement Tracking in Primary Care Practices: Lessons Learned | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/reports/liability/crane.html
     August 01, 2017 - 59 percent Information exchange with other settings 49 percent 53 percent 54 percent Work pressure … Patients’ and doctors’ attitudes to amount of information given after unintended injury during treatment

657. Ten Considerations for Easing the Transition to a Web-based Patient Safety Reporting System (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Ulep.pdf
     January 01, 2004 - dealing with falls, medication safety, lab specimen safety, identification problems, and employee health injuries … Ever-increasing budget pressures often lead to staffing cuts, causing overburdened employees to develop

658. Facilitator Guide: Learning From Defects Through Sensemaking (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
     December 01, 2017 - reengineer the system to catch holes before they line up, and end system gaps that lead to a patient injury … It’s tough when the pressure is high and the patient is at risk.

659. Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Comden.pdf
     January 01, 2003 - as increased medication-borrowing behavior to avoid citations for “drug not available” or the time pressures … Assessing patient safety risk before the injury occurs: an introduction to socio- technical probabilistic

660. AHRQ Safety Program for Perinatal Care: Experiences from the Frontline (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_lowvision.pdf
     May 01, 2017 - Root cause analyses of adverse events and near-misses (events that did not produce patient injury) … The AHRQ Patient Safety Indicator 18 (Obstetric Trauma–Vaginal Delivery with Instrument) decreased … in-house neonatal death, uterine rupture during labor, unplanned maternal admission to ICU, birth trauma … processes at the point of care to include specific maternal parameters, including blood loss, blood pressure … They established a standard process for blood pressure measurement upon admission and during labor